Subjects:
Physical therapy documentation in patient care
Reviewed by: Koncuy Sivrioglu, MD, Physiatrist, Department of Physical Medicine and Rehabilitation, Uludag University School of Medicine, Bursa, Turkey
The book covers fundamentals for documentation within contemporary physical therapy practice. It uses practice exercises and case studies for developing documentation skills needed for current quality standards of patient care
PURPOSE
The book aims to provide a comprehensive reference tool for physical therapy students and practitioners to use when documenting in current practice setting
AUDIENCE
This book can be considered as an excellent source for physical therapy students, educators and practitioners
FEATURES
The text begins with a chapter on comparative description of different disablement models including 1) The International Classification on Functioning, Disability, and Health (ICF) developed and recently revised by WHO, 2) the Nagi framework and 3) the National Center for Medical Rehabilitation Research (NCMRR) disability classification scheme. Following four chapters sequentially provide rationale, basic rules and guidelines for documenting physical therapy evaluation, treatment planning and functional outcome in medical records.
Different documentation formats are presented using multiple examples of clinical cases. Chapters 6 through 9 provide practice for writing different aspects of notes including subjective and objective patient information, assessment, treatment plan, interim and discharge notes. The last three chapters focus on outcome measurement, discussion of regulatory and reimbursement issues which are of utmost importance in terms of documentation. Objectives are provided at the beginning and application exercises are provided at the end of each chapter to facilitate reader's full understanding of practical and theoretical information
ASSESSMENT
This is a valuable reference tool written by subject specialists in relation to a specific aspect of current physical therapy practice. It fully covers essential information and offers plenty of clinical examples assisting the development and improvement of documentation skills for both students and practicing physical therapists
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