Step by step, this text/workbook introduces you to the importance of documentation to support quality patient care and appropriate reimbursement. It shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you'll encounter in practice.
Step by step, this text/workbook introduces you to the importance of documentation to support quality patient care and appropriate reimbursement. It shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you'll encounter in practice.
Retired Program Director/ Professor, San Juan College, Farmington, New Mexico
Inhaltsangabe
* I. Why is Documentation Important? * 1. The World Health Organization and the International Classification of Functioning, Disability and Health * 2. Demystifying the ICD 10 Coding System * 3. Your Documentation Related to Legal and Ethical Issues * 4. Reimbursement Issues Related to Documentation * 5. Physical Therapy Patient Management and Documentation Responsibilities * II. Steps to Documentation * 6. Documentation Content and Organization * 7. Introduction to Documentation * 8. How Does Documentation Relate to Patient Issues * III. How Do SOAP Notes Ensure Good Patient Care? * 9. Introduction to the SOAP Note * 10. What Are Subjective Data and Why Are They Important? * 11. What Are Objective Data and Why Are They Important? * 12. What Are Assessment Data and Why Are They Important? * 13. What Is the Plan and Why Is It Important? * IV. Testing What You Know * 14. Putting Pieces of the Puzzle Together * 15. Do You Know Enough? * Bibliography * Glossary * Appendices * A. Abbreviations * B. Soap Note Rubric * C. Documenting Interventions
* I. Why is Documentation Important? * 1. The World Health Organization and the International Classification of Functioning, Disability and Health * 2. Demystifying the ICD 10 Coding System * 3. Your Documentation Related to Legal and Ethical Issues * 4. Reimbursement Issues Related to Documentation * 5. Physical Therapy Patient Management and Documentation Responsibilities * II. Steps to Documentation * 6. Documentation Content and Organization * 7. Introduction to Documentation * 8. How Does Documentation Relate to Patient Issues * III. How Do SOAP Notes Ensure Good Patient Care? * 9. Introduction to the SOAP Note * 10. What Are Subjective Data and Why Are They Important? * 11. What Are Objective Data and Why Are They Important? * 12. What Are Assessment Data and Why Are They Important? * 13. What Is the Plan and Why Is It Important? * IV. Testing What You Know * 14. Putting Pieces of the Puzzle Together * 15. Do You Know Enough? * Bibliography * Glossary * Appendices * A. Abbreviations * B. Soap Note Rubric * C. Documenting Interventions
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