Documentation for physical therapist assistants

Description

Inside Front Cover Title Page Copyright Dedication Preface Reviewers Acknowledgments Contents PART ONE Why Is Documentation Important? Chapter 1 Introduction to Documentation LEARNING OBJECTIVES INTRODUCTION DOCUMENTATION AND IT SSIGNIFICANCE EVOLUTION OF PT AND PTA RESPONSIBILITIES AND ROLE OF DOCUMENTATION THE ROLE OF DOCUMENTATION IN PATIENT CARE DOCUMENTATION STANDARDS AND CRITERIA SUMMARY REFERENCES Review Exercises Chapter 2 The World Health Organization and the International Classification of Functioning, Disability and Health LEARNING OBJECTIVES INTRODUCTION WHO FAMILY OF INTERNATIONAL CLASSIFICATIONS THE ICF FRAMEWORK SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES Chapter 3 Demystifying the ICD-10 Coding System LEARNING OBJECTIVES INTRODUCTION TRANSITION FROM ICD-9 TO ICD-10 FUNCTIONAL OUTCOMES AND “G” CODES PHYSICIAN QUALITY REPORTING CODING SYSTEM (PQRS) PTA INVOLVEMENT SUMMARY REFERENCES Review Exercises Chapter 4 Reimbursement Issues Related to Documentation LEARNING OBJECTIVES INTRODUCTION MANAGED CARE ORGANIZATIONS (MCOs) MEDICARE MEDICAID PROGRAM OF ALL INCLUSIVECARE FOR THE ELDERLY (PACE) WORKERS’ COMPENSATION INSURANCE OTHER MEDICAL INSURANCE OPTIONS HEALTH-CARE REFORM LAW AND THE AFFORDABLE CARE ACT (ACA) HEALTH CARE AND POTENTIAL CHANGES TO DOCUMENTATION REIMBURSEMENT FOR PT VERSUS PTA STUDENT SERVICES SUMMARY REFERENCES Review Exercises Chapter 5 Documentation Content and Organization LEARNING OBJECTIVES INTRODUCTION WHAT IS BEING DOCUMENTED? TYPES OF MEDICAL RECORDS LOGICAL SEQUENCING OF CONTENT IN THE MEDICAL RECORD FORMATS FOR RECORDING CONTENT SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES Chapter 6 Physical Therapy Patient Management and Documentation Responsibilities LEARNING OBJECTIVES INTRODUCTION FIVE ELEMENTS OF PHYSICAL THERAPY PATIENT MANAGEMENT TYPES AND CONTENT OF EXAMINATIONS AND EVALUATIONS DOCUMENTATION SPECIFICS SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES PART TWO How Do SOAP Notes Ensure Good Patient Care Chapter 7 How Does Documentation Relate to Patient Issues? LEARNING OBJECTIVES INTRODUCTION OUTCOMES ANDTREATMENT PATIENT CONFIDENTIALITY ISSUES COMMUNICATION GUIDELINES:TELEPHONE REFERRALS PROTECTING THE PATIENT SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES Chapter 8 Your Documentation Related to Legal and Ethical Issues LEARNING OBJECTIVES INTRODUCTION PROFESSIONAL LIABILITY INSURANCE LEGAL ISSUES ETHICAL ISSUES SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES PART THREE Steps to Documentation Chapter 9 Introduction to the SOAP Note LEARNING OBJECTIVES INTRODUCTION SUBJECTIVE DATA OBJECTIVE DATA ASSESSMENT PLAN DOCUMENTATION ERRORS EXAMPLES OF SOAP NOTE ORGANIZATION SOAP NOTE RUBRIC CRITICISMS OF SOAP NOTES SUMMARY REFERENCE Review Exercises Chapter 10 What Are Subjective Data and Why Are They Important? LEARNING OBJECTIVES INTRODUCTION SUBJECTIVE DATA ORGANIZING SUBJECTIVE DATA WRITING SUBJECTIVE DATA SUMMARY REFERENCE Review Exercises PRACTICE EXERCISES Chapter 11 What Are Objective Data and Why Are They Important? LEARNING OBJECTIVES INTRODUCTION OBJECTIVE DATA ORGANIZING OBJECTIVE DATA WRITING OBJECTIVE DATA SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES Chapter 12 What Are Assessment Data and Why Are They Important? LEARNING OBJECTIVES INTRODUCTION ASSESSMENT DATA ORGANIZING ASSESSMENT DATA WRITING ASSESSMENT DATA INTERPRETATION OF THE DATA IN THE DAILY NOTE SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES Chapter 13 What Is the Plan and Why Is It Important? LEARNING OBJECTIVES INTRODUCTION TREATMENT PLAN CONTENT SUMMARY REFERENCES Review Exercises PRACTICE EXERCISES PART FOUR Testing What You Know Chapter 14 Putting the Pieces Together LEARNING OBJECTIVES INTRODUCTION REVIEW OF THE SOAP NOTE AN EXAMPLE OF A COMPLETED SOAP NOTE SUMMARY REFERENCE Review Exercises PRACTICE EXERCISES Chapter 15 Do You Know Enough? LEARNING OBJECTIVES INTRODUCTION LICENSING EXAMINATION QUESTIONS THE PTA’S RESPONSIBILITIES LICENSURE REQUIREMENTS FOR PTAs TELEREHABILITATION/ TELEHEALTH ISSUES SUMMARY REFERENCES PRACTICE EXERCISES Bibliography Glossary Appendix A Abbreviations Appendix B Defensible Documentation Elements and Documentation Review Sample Checklist Appendix C SOAP Note Rubric Appendix D Documenting Interventions INDEX