Documentation Basics for the Physical Therapist Assistant

Mia Erickson, Rebecca McKnight

• Publisher: Routledge
• Year: 2024
• Print ISBN: 9781630914028
• eBook ISBN: 9781040142127
• Edition: 3
• Topic: Medicine
• Subtopic: Physiotherapy, Physical Medicine & Rehabilitation

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Third Edition of Documentation Basics for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.

Mia Erickson and Rebecca McKnight have updated this Third Edition to reflect changes in the ever-evolving profession. Newly addressed are the changes in documentation requirements for major payers, changes in the disablement models used, and the increasingly common use of electronic documentation in the physical therapy profession.

Features inside the Third Edition:

• Readers are encouraged to think about disablement and disablement concepts when writing notes
• How to document impairments in body structure and function but more importantly activity limitations and participation restriction
• Descriptions of the differences in documentation methods using a computer vs paper chart
• Evidence tied to benefits and challenges of computerized documentation
• Documenting the rationale for treatment and the unique skills of the physical therapist assistant in patient management

New inside the Third Edition:

• Incorporation of the International Classification of Functioning, Disability, and Health disablement model
• Chapter on electronic documentation
• Screenshot examples of the popular WebPT® electronic medical record platform
• Updated chapters on reimbursement and legal issues
• Additional examples for student practice included in each chapter

Included with the text are online supplemental materials for faculty use in the classroom.

Documentation Basics for the Physical Therapist Assistant, Third Edition is the perfect guide for all physical therapist assistant students and clinicians who want to update and refine their knowledge and skills in documentation.

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Authors
• Preface
• Chapter 1 Disablement and Physical Therapy Documentation
• Chapter 2 The Physical Therapy Episode of Care
• Chapter 3 Reasons for Documenting
• Chapter 4 Documentation Formats
• Chapter 5 Electronic Medical Record
• Chapter 6 Basic Guidelines for Documentation
• Chapter 7 Interpreting the Physical Therapist Initial Evaluation
• Chapter 8 Writing the Subjective Section
• Chapter 9 Writing the Objective Section
• Chapter 10 Writing the Assessment and Plan Sections
• Chapter 11 Payment Basics
• Chapter 12 Legal and Ethical Considerations for Physical Therapy Documentation
• Chapter 13 Documentation Across the Curriculum
• Appendix: Abbreviations and Symbols
• Index