(Ebook) Writing Patient Client Notes Ensuring Accuracy in Documentation 5th Edition by Ginge Kettenbach, Sarah L Schlomer, Jill Fitzgerald ISBN 0803638205 9780803638204

(Ebook) Writing Patient Client Notes Ensuring Accuracy in Documentation 5th Edition by Ginge Kettenbach, Sarah L Schlomer, Jill Fitzgerald ISBN 0803638205 9780803638204

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ISBN 10: 0803638205 
ISBN 13: 9780803638204
Author: Ginge Kettenbach, Sarah L Schlomer, Jill Fitzgerald

Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes.This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

(Ebook) Writing Patient Client Notes Ensuring Accuracy in Documentation 5th Table of contents:

Chapter 1 Introduction to Documentation
Sections of This Textbook
How to Use This Book
Summary
Reference
Part I The Health Record
Chapter 2 Overview of the Health Record
Overview of the Health Record
Maintaining a Health Record
Ensuring Quality Documentation in the Health Record
Locating Information in the Paper Health Record
The Electronic Health Record
Summary
References
Chapter 3 Legal Aspects of the Health Record
The Health Insurance Portability and Accountability Act and Protected Health Information
Keeping Health Information Secure
Maintaining Confidentiality
Releasing Confidential Information
Faxing or E-Mailing Patient Information
Health Record Retention
Electronic Signatures
Summary
References
Chapter 4 Reimbursement
Reimbursement Process
Reimbursement by Third-Party Payors
Billing for Service
Summary
References
Chapter 5 Reviewing the Health Record as a Physical Therapist
Sections of the Health Record
Summary and Objective
The Purposes of Documentation in Physical Therapy
Part II Documentation Basics
Chapter 6 Writing in a Health Record
Writing to Document Therapy
Examples of Errors in Accuracy, Brevity, and Clarity
References
Summary and Objective
Chapter 7 Introduction to Note Writing
The Patient/Client Management Note
The SOAP Note
Documenting the Patient/Client Management Process Using the Patient/Client Management Note and the S
The Four Types of Patient/Client Care Notes: Initial, Daily, Progress/Re-evaluation, and Discharge N
Documentation by the Physical Therapist Assistant or Occupational Therapy Assistant
Summary and Objective
References
Chapter 8 Medical Terminology
Summary and Objective
Reference
Worksheet
Chapter 9 Using Abbreviations
Approved Abbreviations and Symbols for Healthcare Facility XYZ
Using Abbreviations: Examples
Summary and Objective
References
Worksheet
Chapter 10 Introduction to Documentation Using the International Classification of Functioning, Dis
Background on ICF
The ICF Model and Terminology
Performance and Capacity Qualifiers in ICF Coding
National and International Implementation of ICF Codes
Integrating ICF Into Current Documentation Practices
ICF and Expected Outcomes
ICF and Anticipated Goals
Summary and Objective
References
Part III Documenting the Examination
Chapter 11 The Patient/Client Management Format:
The Review of Systems
Performing the Review of Systems in Various Practice Settings
Organization of the Review of Systems
Documenting the Review of Systems
Use of the Term
Abbreviations and Medical Terminology
Organization
Progress Notes
Discharge Summaries
Summary and Objective
References
Exercise: Review of Systems
Chapter 12 The Patient/Client Management Format:
The Systems Review
Categorizing Items Into Tests and Measures
Abbreviations and Medical Terminology
Categories
Methods of Recording Data From Tests and Measures
Common Mistakes in Recording Data From Tests and Measures
Writing Re-evaluation/ Progress Notes
Writing Discharge Notes
Summary and Objective
References
Worksheet
Chapter 13 The SOAP Note:
Categorizing Items as Subjective
The Review of Systems
Performing the Review of Systems in Various Practice Settings
Organization of the Review of Systems
Documenting the Review of Systems
Use of the Term
Abbreviations and Medical Terminology
Organization
Verbs
Quoting the Patient/Client Verbatim
Using Information Taken From a Family Member
Writing Re-Evaluation/ Progress Notes
Writing Discharge Notes
Summary and Objective
References
Exercise: Review of Systems
Chapter 14 The SOAP Note:Writing Subjective (S), Includingthe Review of Systems
Categorizing Items as Subjective
The Review of Systems
Organization of the Reviewof Systems
Performing the Review of Systemsin Various Practice Settings
Documenting the Reviewof Systems
Writing Re-Evaluation/Progress Notes
Writing Discharge Notes
Summary and Objective
References
Chapter 15 The SOAP Note:
The Systems Review
Tests and Measures
Writing Progress/Re-Evaluation Notes
Writing Discharge Notes
Summary and Objective
References
Worksheet
Part IV Documentingthe Evaluation/Assessment (A)
Chapter 16 Writing the Evaluation/ Assessment (A)
Discussing the Patient’s Progress in Re-evaluation/Progress Notes
Summary and Objective
References
Chapter 17 Writing the Diagnosis (A: DIAGNOSIS)
The Therapy Diagnosis
Differences Between a Therapy Diagnosis and a Medical Diagnosis
Critical Issues Statement
Physical Therapy Diagnostic Categories
Including ICD-10 Codes
Summary and Objective
References
Chapter 18 Writing the Prognosis (A: PROGNOSIS)
Factors Influencing the Prognosis
Justification for Patient Goals or Treatment Plan; Clarification of a Problem
Future Services Needed
Justification for Further Therapy
Revision of Prognosis
Summary and Objective
References
w o r k s h e e t
Review Worksheet Patient/Client Managment Format:
Part V Documentingthe Plan of Care (P)
Chapter 19 Writing Expected Outcomes and Anticipated Goals
Reasons for Writing Outcomes and Goals
The Basic Structure of Expected Outcomes and Anticipated Goals
Key Components of All Goals
Modifying Expected Outcomes and Anticipated Goals
Discharge Summaries
Summary and Objective
References
Worksheet
Chapter 20 Documenting the Intervention Plan
Relationship to Anticipated Goals
Information Included in the Intervention Plan
Summary and Objective
References
w o r k s h e e t
Part VI Applications ofDocumentation Skills
Chapter 21 Writing the Daily Visit Note
Missed Scheduled Visits
Summary and Objective
References
w o r k s h e e t
Chapter 22 The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes)
Medicare Therapy Cap and KX Modifiers
Functional Limitations Reporting
Summary
References
Chapter 23 Applications and Variations in Note Writing
Applying the Patient/Client Management Note to Other Note Formats
Uses in Clinical Decision-Making
Computerized Documentation
Documenting All Types of Patient Care

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Tags: Ginge Kettenbach, Sarah L Schlomer, Jill Fitzgerald, Patient, Client