Everything the physical therapists needs to know about the documentation process in one clear, concise, easy-to-follow text
Effective Documentation for Physical Therapy Professionals is your best choice for gaining a solid understanding of the entire physical therapy documentation process. There is no faster or easier way to learn the when, what, and how of physical therapy documentation than this trusted guide. The second edition has been updated to include the most recent professional guidelines, codes, and methodologies and covers timely subjects such as Medicare, electronic record keeping, legal issues, pediatric documentation, utilization review and management, and much more.
With Effective Documentation for Physical Therapy Professionals, you will learn how to incorporate all of the general principles of documentation and health information management in order to effectively maintain and organize records, record appropriate information, and receive proper reimbursement based on the documentation content.
Master All Aspects of PT Documentation With:
APTA Standards and Guidelines,Medicare,Home Health,Electronic Record Keeping,ICF Model and Application,Pediatrics,Legal Issues,Utilization Review & Management,SNF: RUGS and MDS,Sample Documentation Content,Initial Examination and Evaluation Criteria,Continuum of Care Content and Goal Writing Exercises,Documentation Aspects of Supervising PTAs,Abbreviations,Reimbursement,ICD9 and CPT Codes and Application,Chapter Review Questions,Content Principles.
Chapter 1. Introduction, Background, Purpose and General Rules for Health Information Management (Medical Record Keeping)Chapter 2. Record Organization and General PrinciplesChapter 3. Application of Models for Organization and Guidelines for ContentChapter 4. Content Standardization/Component RequirementsChapter 5. Coding and DocumentationChapter 6. Home Health DocumentationChapter 7. Legal Issues in the Medical RecordChapter 8. MDS Purpose and ComponentsChapter 9. Medicare and Non-Medicare Content PrinciplesChapter 10. Pediatric DocumentationChapter 11. The Electronic Medical RecordChapter 12. Utilization Review and Utilization ManagementAppendix A: AbbreviationsAppendix B: CMS 700 Form and CS-1786 HIPPA Disclosure FormAppendix C: CMS Forms 1450 and 1500 with InstructionsAppendix D: ICD-9 Code TermsAppendix E: APTA Guidelines for Physical Therapy Documentation and Guidelines for Group CodingAppendix F: Goal Writing ExerciseAppendix G: Note Writing ExerciseAppendix H: Documentation Content ExerciseAppendix I: Documentation Content Examples