Documentation for Rehabilitation, 3rd Edition

By Lori Quinn, EdD, PT and James Gordon, EdD, PT
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  • UNIQUE! Combination textbook/workbook format reinforces your understanding and tests your ability to apply concepts through practice exercises.
  • UNIQUE! Systematic approach to documenting functional outcomes provides a practical framework for success in numerous practice settings.
  • Case studies show you how to format goals through realistic client examples.
  • Practice exercises provide valuable experience applying concepts to common clinical problems.

Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning.

Key Features
  • A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA.
  • Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
  • Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
  • Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.
ISBN 9780323312332
Product Format Book
Publication Date 2015
Author Information By Lori Quinn, EdD, PT, Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY and James Gordon, EdD, PT, Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA
Published Reviews

"A clear and concise message with a rigid format which has something for newbies and seasoned pros"

"easily accessible, easy to follow and easy to use with enough complexity to cater for all needs."

1. Disablement Models, ICF Framework and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation
4. Standardized Outcome Measures  NEW!
5. Payment Policy and Coding
6 Electronic Medical Records
7. Clinical Decision Making and the Initial Evaluation Format  
8. Documenting Reason for Referral: Health Condition and Participation
9. Documenting Activities
10. Documenting Impairments
11. Document the Assessment: Summary and Diagnosis
12. Developing and Documenting Effective Goals
13. Documenting the Plan of Care
14. Documenting Session Notes and Progress Notes Using a Modified SOAP Note Format
15. Special Formats: Documenting Screenings, Discharge Summaries, Letters and Patient Education Materials
16. Documentation in Pediatrics  
Appendix A:  Guidelines: Physical Therapy Documentation of Patient/Client Management
Appendix B: Rehabilitation Abbreviations
Appendix C: Answers to Exercises
Appendix D:  Documentation Review Sample Checklist
  Appendix E: Strength and Range of Motion Forms
Publication Date 11-12-2015
Pages 276
Trim 276 x 216 (8 1/2 x 10 7/8)
Stock Status In Stock
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