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

Documentation Basics: A Guide for the Physical Therapist Assistant

byMia Erickson, Becky McknightEditorMia Erickson

Paperback | May 15, 2012

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Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The newSecond EditionofDocumentation Basics: A Guide for the Physical Therapist Assistantcontinues 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 insideDocumentation Basics: A Guide for the Physical Therapist Assistant, Second Edition:

• The discussion on integrating disablement into documentation
• The discussion on how a PTA can show medical necessity and need for skilled care
• The discussion on using documentation to communicate with other providers
• Writing the assessment and plan to coincide with the initial documentation
• Sample notes completed on forms
• More 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 Practice
• Medicare reimbursement in different settings
• The importance of consistent, reliable, and valid measurements
• How to improve communication and consistency between documentation by the PT & the PTA

The 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 insideDocumentation Basics: A Guide for the Physical Therapist Assistant, Second Edition:
• Navigating the PT plan of care... step-by-step model for PTAs to use as they navigate the initial PT documentation and plan of care
• How the PTA uses the PT goals from the initial examination and evaluation
Positive and negative aspects of using electronic documentation and a discussion on integrating SOAP notes and the problem-oriented medical record into electronic documentation
• Sample notes and discussion of documentation in school-based settings, early intervention, skilled nursing settings, in-patient rehabilitation, and direct access
• Medicare Parts C and D
• Cash-based services and pro bono services


Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom.

Documentation Basics: A Guide for the Physical Therapist Assistant, Second Editionis the perfect guide for all physical therapist assistant students and clinicians who want to update and refine their knowledge and skills in documentation.

Mia L. Erickson, PT, EdD, CHT, ATCis currently an Associate Professor and Co-Academic Coordinator of Clinical Education at West Virginia University. She has a bachelor's degree in secondary education and athletic training from West Virginia University. She received a master of science degree in physical therapy from the University of I...
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Title:Documentation Basics: A Guide for the Physical Therapist AssistantFormat:PaperbackDimensions:176 pages, 11 × 8.5 × 0.5 inPublished:May 15, 2012Publisher:Slack IncorporatedLanguage:English

The following ISBNs are associated with this title:

ISBN - 10:1617110086

ISBN - 13:9781617110085

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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
Patient's 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 Patient's Response to Intervention
Patient's 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