Documentation for the Physical Therapist Assistant

Step by step, this text/workbook introduces you to the importance of documentation and shows you how to develop and write a proper and defensible note for all forms of reimbursement. Review questions and practice exercises help you remember must-know information and examples of appropriate and inappropriate notes show what and what not to do. You'll also explore the important issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society. And, all the terminology adheres to the upcoming and newly revised APTA's Guide.

LOGICAL SEQUENCING OF CONTENT IN THE MEDICAL RECORD.

Copyright ; Preface ; Reviewers ; Acknowledgments ; Contents ; Part One: Why Is Documentation Important?; Chapter 1: Introduction to Documentation; LEARNING OBJECTIVES ; INTRODUCTION; DOCUMENTATION AND ITS SIGNIFICANCE; Evidence of Patient Care; Accountability for Patient Care; An Example of the Importance of Documentation; The Experience; EVOLUTION OF PT AND PTA RESPONSIBILITIES AND THE ROLE OF DOCUMENTATION; Major Influences on PT and PTA Responsibilities; Changes in Referrals for Physical Therapy; THE PHYSICAL THERAPY PRESCRIPTION; PTS ABLE TO EVALUATE AND TREAT.

DIRECT ACCESS TO PHYSICAL THERAPYEstablishment of Medicare; Documentation Classifications and Models; FUNCTION VERSUS IMPAIRMENT; Physical Therapy Services Today; THE ROLE OF DOCUMENTATION IN PATIENT CARE; DOCUMENTATION STANDARDS AND CRITERIA; Federal Government; State Governments; Professional Associations; Accrediting Agencies; Health-Care Facilities; SUMMARY; REFERENCES; Review Exercises; Chapter 2: The World Health Organization and the International Classification of Functioning, Disability and Health; LEARNING OBJECTIVES; INTRODUCTION; WHO FAMILY OF INTERNATIONAL CLASSIFICATIONS.

THE ICF FRAMEWORKThe American Ph…