I. Why is Documentation Important?
1. The World Health Organization and the International Classification of Functioning, Disability and Health
2. Demystifying the ICD 10 Coding System
3. Your Documentation Related to Legal and Ethical Issues
4. Reimbursement Issues Related to Documentation
5. Physical Therapy Patient Management and Documentation Responsibilities
II. Steps to Documentation
6. Documentation Content and Organization
7. Introduction to Documentation
8. How Does Documentation Relate to Patient Issues
III. How Do SOAP Notes Ensure Good Patient Care?
9. Introduction to the SOAP Note
10. What Are Subjective Data and Why Are They Important?
11. What Are Objective Data and Why Are They Important?
12. What Are Assessment Data and Why Are They Important?
13. What Is the Plan and Why Is It Important?
IV. Testing What You Know
14. Putting Pieces of the Puzzle Together
15. Do You Know Enough?
B. Soap Note Rubric
C. Documenting Interventions
Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation to support quality patient care and appropriate reimbursement. It shows you how to develop and write a proper and defensible note and prepares you to meet the technological challenges you’ll encounter in practice.
You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.
• Explores all aspects of SOAP notes with review questions and practice exercises that help students remember must-know information.
• Demonstrates what to do and what not to do through examples of appropriate and inappropriate notes.
• Teaches procedures for multiple practice settings with examples of various types of documentation and forms that prepare you for the real world.
• Provides example of notes from the different types of settings in which PTAs practice, including hospitals, acute orthopedic, rehabilitation, nursing homes, outpatient, and pediatrics as well as different types of diagnoses related to the notes.
• Follows the standards of the APTA’s Guide to Physical Therapy Practice with the proper terminology.
New To This Edition:
• Updated, reviewed & revised! Thoroughly updated, reviewed, and revised throughout to reflect the latest guidelines, documentation procedures, and technologies.
• New! Narrated videos of patient treatment sessions online at FADavis.com that offer students practice completing SOAP notes that emulate electronic records documentation.
• New! Patient Treatment Observation Form for students to complete after re-watching the videos to record any discrepancies or inappropriate treatment techniques they might view.
• Updated & revised! The latest guidelines, including the American Physical Therapy Association's (APTA) Guide to Physical Therapist Practice (revised 2014) and the impact of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) on proper documentation.
• Updated & Revised! Coverage that reflects the discontinuation of the Patient Quality Reporting System (PQRS) and the initiation of the Merit Based Incentive Payment System (MIPS), as well as CMS’s change from a fee-for-service structure to a patient-driven payment system in skilled nursing facilities (SNFs) and the change to patient-driven groupings model (PDGM) for home health agencies.