Physical Therapy Documentation

From Examination to Outcome

Mia Erickson, Ralph Utzman, Rebecca McKnight

• Publisher: Routledge
• Year: 2024
• Print ISBN: 9781630916268
• eBook ISBN: 9781040137024
• Edition: 3
• Topic: Medicine
• Subtopic: Physiotherapy, Physical Medicine & Rehabilitation

Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice.

Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone.

Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on:

• Health informatics
• Electronic medical records
• Rules governing paper and electronic records
• Billing, coding, and outcomes measures

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

An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners.

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• Acknowledgments
• About the Authors
• Preface
• Chapter 1 Disablement and Documentation
• Chapter 2 Reasons for Documenting in Physical Therapy
• Chapter 3 Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation
• Chapter 4 Documenting Patient/Client Management: An Overview
• Chapter 5 Documentation Formats
• Chapter 6 Health Informatics and Electronic Health Records
• Chapter 7 Rules for Writing in Medical Records
• Chapter 8 Documenting the Examination
• Chapter 9 Documenting the Evaluation
• Chapter 10 Interim Documentation
• Chapter 11 Patient Outcomes and Discharge Summaries
• Chapter 12 Documentation, Insurance, and Payment
• Appendix: Abbreviations and Symbols
• Index