Table
of Contents
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Acknowledgments |
ix |
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About the
Authors |
xi |
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Preface |
xiii |
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Chapter 1 |
Physical Therapy and Disablement Mia L.
Erickson, PT, EdD, CHT, ATC |
1 |
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Chapter Objectives |
1 |
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Defining Health and Disability |
1 |
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The Nagi
Framework |
2 |
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The ICF |
3 |
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Physical Therapy and Disablement: Going
Beyond Impairment |
6 |
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Disablement and Documentation |
6 |
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Review Questions |
7 |
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Application Exercises |
8 |
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Chapter 2 |
Reasons for Documenting Mia L.
Erickson, PT, EdD, CHT, ATC |
9 |
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Chapter Objectives |
9 |
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Legal and Ethical Responsibility |
9 |
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Record Patient Data |
10 |
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Record Patient Care |
11 |
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Provide Proof That Care Is “Reasonable
and Necessary” |
11 |
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Skilled Care |
12 |
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Demonstrate the Clinical
Decision-Making Process |
12 |
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Review Questions |
14 |
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Application Exercises |
15 |
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Chapter 3 |
Documentation Formats Mia L.
Erickson, PT, EdD, CHT, ATC |
19 |
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Chapter Objectives |
19 |
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Narrative |
19 |
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Problem-Oriented Medical Record |
20 |
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SOAP Notes |
21 |
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Functional Outcomes Reporting |
25 |
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Templates and Fill-In Forms |
26 |
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The Electronic Medical Record |
26 |
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IDEA, IFSPs,
and IEPs |
27 |
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Review Questions |
29 |
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Application Exercises |
30 |
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Chapter 4 |
The Physical Therapy Process Rebecca
McKnight, PT, MS |
33 |
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Chapter Objectives |
33 |
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Introduction |
33 |
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The Physical Therapy Process |
33 |
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Physical Therapist and Physical
Therapist Assistant Roles |
36 |
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Coordination, Communication, and
Documentation |
37 |
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Review Questions |
39 |
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Application Exercises |
40 |
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Chapter 5 |
Interpreting the Initial Evaluation Rebecca McKnight, PT, MS |
41 |
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Chapter Objectives |
41 |
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Introduction |
41 |
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Documentation Continuum in Physical
Therapy |
41 |
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SOAP Initial Evaluative Note |
42 |
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How to Use the Initial Evaluative
Note |
49 |
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Additional Questions to Answer |
51 |
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Review Questions |
54 |
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Application Exercises |
55 |
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Chapter 6 |
Basic Guidelines for Documentation Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD,
ATC, CHT |
61 |
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Chapter Objectives |
61 |
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Documentation in Physical Therapy |
61 |
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Basic Principles |
62 |
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Top 10 Reasons for Denials From
Payers |
64 |
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Documenting Patient Care |
64 |
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Review Questions |
66 |
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Application Exercises |
67 |
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Chapter 7 |
Writing the Subjective Section Rebecca
McKnight, PT, MS |
73 |
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Chapter Objectives |
73 |
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Introduction |
73 |
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Where Does It Come From? |
73 |
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Problem (Pr) |
74 |
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Subjective (S) |
74 |
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Review Questions |
76 |
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Application Exercises |
77 |
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Chapter 8 |
Writing the Objective Section Rebecca McKnight, PT, MS |
79 |
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Chapter Objectives |
79 |
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Introduction |
79 |
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The Interim Note |
79 |
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Intervention Provided |
80 |
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Data That Indicate That It Is Safe
for the Patient to Participate in the Selected Interventions |
80 |
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Patient’s Response to Physical Therapy
Intervention Provided |
80 |
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Structure/Organization of O |
80 |
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General Tips |
81 |
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Tips for Documenting Interventions
Provided |
81 |
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Tips for Documenting Results of Data
Collected |
83 |
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Types of Data Collected |
83 |
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Describing Patient Function |
83 |
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Observations |
84 |
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Review Questions |
87 |
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Application Exercises |
88 |
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Chapter 9 |
Writing the Assessment and Plan Rebecca McKnight, PT, MS |
91 |
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Chapter Objectives |
91 |
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Introduction |
91 |
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Importance of Documenting the
Assessment (A) |
91 |
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Explanation of How the Data
Demonstrate the Patient’s Response to Intervention |
92 |
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Patient’s Progress Toward Goals |
92 |
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Plan (P) |
92 |
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Pulling It All Together |
93 |
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Structure of an Interim SOAP Note |
93 |
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Review Questions |
94 |
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Application Exercises |
94 |
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Chapter 10 |
Payment Basics Mia L.
Erickson, PT, EdD, CHT, ATC |
97 |
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Chapter Objectives |
97 |
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What Is Reimbursement? |
97 |
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Types of Payment |
97 |
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Documentation and Reimbursement |
101 |
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Review Questions |
103 |
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Application Exercise |
104 |
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Chapter 11 |
Legal and Ethical Considerations for Physical Therapy
Documentation Mia L. Erickson, PT, EdD, CHT, ATC |
105 |
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Chapter Objectives |
105 |
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Introduction |
105 |
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Patient Privacy and Confidentiality |
105 |
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Fraud and Abuse |
107 |
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Risk Management |
107 |
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Establishing Documentation
Requirements |
107 |
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Review Questions |
109 |
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Chapter 12 |
SOAP Notes Across the Curriculum Mia L.
Erickson, PT, EdD, CHT, ATC |
111 |
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Goniometry |
111 |
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Strength Assessment |
112 |
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Therapeutic Exercises |
112 |
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Transfers |
113 |
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Tilt Table |
114 |
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Wheelchair Management |
114 |
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Gait Training |
115 |
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Wound Care |
116 |
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Chronic Obstructive Pulmonary
Disease/Vital Signs |
117 |
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Traumatic Brain Injury Tracy
Rice, PT, MPH,.NCS |
117 |
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Spinal Cord Injury Tracy Rice,
PT, MPH, NCS |
118 |
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Cerebrovascular Accident |
118 |
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Lower Extremity Amputation/Prosthetic
Devices |
120 |
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Musculoskeletal Trauma |
122 |
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Pediatric/Orthotic
Devices |
124 |
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Glossary |
127 |
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Appendix A |
Abbreviations
and Symbols |
131 |
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Appendix B |
Sample
Forms and Templates Jeff
Erickson, PT, MS, SCS, ATC, CSCS |
137 |
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Financial
Disclosures |
151 |
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Index |
153 |
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