Documentation Basics: A Guide for the Physical Therapist Assistant by Mia Ericks

Description: Documentation Basics by Mia Erickson, Rebecca McKnight Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. This new second edition continues the path of teaching the student and clinician documentation from A to Z. It has been updated to reflect changes of the American Physical Therapy Association and the ever-evolving profession. FORMAT Paperback LANGUAGE English CONDITION Brand New Publisher Description Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new "Second Edition "of "Documentation Basics: A Guide for the Physical Therapist Assistant "continues the path of teaching the student and clinician documentation from A to Z.Mia Erickson and Rebecca McKnight have updated this Second Edition to reflect changes of the American Physical Therapy Association and the ever-evolving profession.Updated inside "Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition"The discussion on integrating disablement into documentationThe discussion on how a PTA can show medical necessity and need for skilled careThe discussion on using documentation to communicate with other providersWriting the assessment and plan to coincide with the initial documentationSample notes completed on formsMore examples and practice, including physical agents, school-based services, pediatrics, traumatic brain injury, spinal cord injury, and interventions consistent with the Guide to Physical Therapist PracticeMedicare reimbursement in different settingsThe importance of consistent, reliable, and valid measurementsHow to improve communication and consistency between documentation by the PT & the PTAThe discussion on disablement has also been updated, shifting away from the Nagi Model toward the International Classification of Functioning, Disability, and Health (ICF). In addition, the PTA Normative Model has been integrated throughout to include more information on clinical decision making.New inside "Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition"Navigating the PT plan of care...A step-by-step model for PTAs to use as they navigate the initial PT documentation and plan of careHow the PTA uses the PT goals from the initial examination and evaluationPositive and negative aspects of using electronic documentation and a discussion on integrating SOAP notes and the problem-oriented medical record into electronic documentationSample notes and discussion of documentation in school-based settings, early intervention, skilled nursing settings, in-patient rehabilitation, and direct accessMedicare Parts C and DCash-based services and pro bono servicesInstructors in educational settings can for additional material to be used for teaching in the classroom."Documentation Basics: A Guide for the Physical Therapist Assistant, Second Edition "is the perfect guide for all physical therapist assistant students and clinicians who want to update and refine their knowledge and skills in documentation. Author Biography Mia L. Erickson, PT, EdD, ATC, CHT Dr. Erickson is the former Program Director of the Physical Therapist Assistant Program at Allegany College of Maryland. Currently she is an Assistant Professor and Co-Academic Coordinator of Clinical Education at West Virginia University. She has a Bachelors Degree in Secondary Education and Athletic Training from West Virginia University and a Master of Science Degree in Physical Therapy from the University of Indianapolis. She completed her doctoral work at West Virginia University with emphasis in curriculum and instruction. She maintains clinical pr Table of Contents Acknowledgments About the Authors Preface Chapter 1 Physical Therapy and Disablement Mia L. Erickson, PT, EdD, CHT, ATC Chapter Objectives Defining Health and Disability The Nagi Framework The ICF Physical Therapy and Disablement: Going Beyond Impairment Disablement and Documentation Review Questions Application Exercises Chapter 2 Reasons for Documenting Mia L. Erickson, PT, EdD, CHT, ATC Chapter Objectives Legal and Ethical Responsibility Record Patient Data Record Patient Care Provide Proof That Care Is "Reasonable and Necessary" Skilled Care Demonstrate the Clinical Decision-Making Process Review Questions Application Exercises Chapter 3 Documentation Formats Mia L. Erickson, PT, EdD, CHT, ATC Chapter Objectives Narrative Problem-Oriented Medical Record SOAP Notes Functional Outcomes Reporting Templates and Fill-In Forms The Electronic Medical Record IDEA, IFSPs, and IEPs Review Questions Application Exercises Chapter 4 The Physical Therapy Process Rebecca McKnight, PT, MS Chapter Objectives Introduction The Physical Therapy Process Physical Therapist and Physical Therapist Assistant Roles Coordination, Communication, and Documentation Review Questions Application Exercises Chapter 5 Interpreting the Initial Evaluation Rebecca McKnight, PT, MS Chapter Objectives Introduction Documentation Continuum in Physical Therapy SOAP Initial Evaluative Note How to Use the Initial Evaluative Note Additional Questions to Answer Review Questions Application Exercises Chapter 6 Basic Guidelines for Documentation Rebecca McKnight, PT, MS and Mia L. Erickson, PT, EdD, ATC, CHT Chapter Objectives Documentation in Physical Therapy Basic Principles Top 10 Reasons for Denials From Payers Documenting Patient Care Review Questions Application Exercises Chapter 7 Writing the Subjective Section Rebecca McKnight, PT, MS Chapter Objectives Introduction Where Does It Come From? Problem (Pr) Subjective (S) Review Questions Application Exercises Chapter 8 Writing the Objective Section Rebecca McKnight, PT, MS Chapter Objectives Introduction The Interim Note Intervention Provided Data That Indicate That It Is Safe for the Patient to Participate in the Selected Interventions Patients Response to Physical Therapy Intervention Provided Structure/Organization of O General Tips Tips for Documenting Interventions Provided Tips for Documenting Results of Data Collected Types of Data Collected Describing Patient Function Observations Review Questions Application Exercises Chapter 9 Writing the Assessment and Plan Rebecca McKnight, PT, MS Chapter Objectives Introduction Importance of Documenting the Assessment (A) Explanation of How the Data Demonstrate the Patients Response to Intervention Patients Progress Toward Goals Plan (P) Pulling It All Together Structure of an Interim SOAP Note Review Questions Application Exercises Chapter 10 Payment Basics Mia L. Erickson, PT, EdD, CHT, ATC Chapter Objectives What Is Reimbursement? Types of Payment Documentation and Reimbursement Review Questions Application Exercise Chapter 11 Legal and Ethical Considerations for Physical Therapy Documentation Mia L. Erickson, PT, EdD, CHT, ATC Chapter Objectives Introduction Patient Privacy and Confidentiality Fraud and Abuse Risk Management Establishing Documentation Requirements Review Questions Chapter 12 SOAP Notes Across the Curriculum Mia L. Erickson, PT, EdD, CHT, ATC Goniometry Strength Assessment Therapeutic Exercises Transfers Tilt Table Wheelchair Management Gait Training Wound Care Chronic Obstructive Pulmonary Disease/Vital Signs Traumatic Brain Injury Tracy Rice, PT, MPH, NCS Spinal Cord Injury Tracy Rice, PT, MPH, NCS Cerebrovascular Accident Lower Extremity Amputation/Prosthetic Devices Musculoskeletal Trauma Pediatric/Orthotic Devices Glossary Appendix A: Abbreviations and Symbols Appendix B: Sample Forms and Templates Jeff Erickson, PT, MS, SCS, ATC, CSCS Financial Disclosures Index Details ISBN1617110086 Author Rebecca McKnight Publisher SLACK Incorporated Year 2012 Edition 2nd ISBN-10 1617110086 ISBN-13 9781617110085 Format Paperback Imprint SLACK Incorporated Subtitle A Guide for the Physical Therapist Assistant Place of Publication Thorofare Country of Publication United States Pages 176 Qualifications Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Edd, MS, PT, Atc Short Title DOCUMENTATION BASICS 2/E Language English Media Book DEWEY 615.82 Illustrations Yes Residence US Publication Date 2012-05-01 AU Release Date 2012-05-01 NZ Release Date 2012-05-01 US Release Date 2012-05-01 UK Release Date 2012-05-01 Replaced by 9781630914028 We've got this At The Nile, if you're looking for it, we've got it. 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