Writing patient/client notes : ensuring accuracy in documentation /
Saved in:
| Online Access: |
Full text (MCPHS users only) |
|---|---|
| Main Authors: | , |
| Format: | Electronic eBook |
| Language: | English |
| Published: |
Philadelphia :
F.A. Davis Company,
2016
|
| Edition: | 5th edition. |
| Subjects: |
Table of Contents:
- Introduction to documentation
- Part I: The health record. Overview of the health record
- Legal aspects of the health record
- Reimbursement
- Reviewing the health record as a physical therapist
- Part II: Documentation basics. Writing in a health record
- Introduction to note writing
- Medical terminology
- Using abbreviations
- Introduction to documentation using the international classification of functioning, disability, and health (ICF) system
- Part III: Documenting the examination. The patient/client management format: writing history, including the review of systems
- The patient/client management format: writing systems review and tests and measures
- The SOAP note: stating the problem
- The SOAP note: writing subjective (S), including the review of systems
- The SOAP note: writing objective (O)
- Part IV: Documenting the evaluation/assessment (A). Writing the evaluation/assessment (A)
- Writing the diagnosis (A: diagnosis)
- Writing the prognosis (A: prognosis)
- Part V: Documenting the plan of care (P). Writing expected outcomes and anticipated goals
- Documenting the intervention plan
- Part VI: applications of documentation skills. Writing the daily visit note
- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes)
- Applications and variations in note writing
- Appendices. Summary of the patient/client management note contents
- Summary of the SOAP note contents
- Summary of contents of the four types of notes
- Tips for note writing for third-party payors
- Review of systems and systems review forms
