1

Why is Documentation Important?

1

Introduction to Documentation?

2

The World Health Organization and the International Classification of Functioning, Disability and Health

3

Reimbursement Issues Related to Documentation

4

Documentation Content and Organization

5

Physical Therapy Patient Management and Documentation Responsibilities

2

Steps to Documentation

6

Introduction to the SOAP Note

7

What Is Subjective Data and Why Is It Important?

8

What Is Objective Data and Why Is It Important?

9

What Is Assessment Data and Why Is It Important?

10

What Is the Plan and Why Is It Important?

11

Putting the Pieces of the Puzzle Together

3

How Do SOAP Notes Ensure Good Patient Care?

12

How Does Documentation Relate to Patient Issues?

13

Your Documentation Related to Legal and Ethical Issues

4

Testing What You Know

14

Do You Know Enough?

Bibliography

Glossary

APPENDICES

Appendix A

Abbreviations (from last edition)

Appendix B

Defensible Documentation Elements and Review Documentation Checklist (New)

Appendix C

SOAP Note Rubric (New)

Appendix D

Documenting Interventions (Appendix B from last edition)

Index