Writing patient/client notes ensuring accuracy in documentation

• Main Author: Kettenbach, Ginge (Author)
• Format: Book
• Language: English
• Published: Philadelphia F.A. Davis 2009
• Edition: Fourth Edition
• Subjects: Medical History Taking > Problems and Exercises; Physical Therapy Modalities > Problems and Exercises; Physical Therapy Specialty > Problems and Exercises; Writing > Problems and Exercises
• Online Access: Click Here to View Status and Holdings.

This is an ideal resource for any health care professional needing to learn or improve their skills - with simple, straightforward 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 mod...

Table of Contents:

• Introduction to note writing
• Writing in a medical record
• Medical terminology
• Using abbreviations
• The patient/client management note : writing history
• The patient/client management note : writing the systems
• The patient/client management format : documenting tests and measures
• The SOAP note : stating the problem
• The SOAP note : writing subjective (S)
• The SOAP note : writing objective (O)
• Writing evaluation (A: EVALUATION)
• Writing the diagnosis (A: DIAGNOSIS)
• Writing the prognosis
• Writing expected outcomes (long-term goals)
• Writing anticipated goals (short-term goals)
• Documenting planned interventions
• Overview of the medical record / Jody Smith
• Legal aspects of the medical record / Jody Smith
• Reimbursement / Jeanne Donnelly
• Applications and variations in note writing
• Alternatives : documentation forms and computerized documentation
• The future : documentation using the International Classification of Functiong, disability and health (ICF) system / Theresa Bernsen.