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Writing Patient/Client Notes : Ensuring Accuracy in Documentation by Sarah Lynn
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USD5,38 (aprox. 4,64 EUR) USPS Media MailTM.
Ubicado en: Canton, New York, Estados Unidos
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Entrega prevista entre el mié. 18 jun. y el mié. 25 jun. a 94104
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N.º de artículo de eBay:285898136618
Características del artículo
- Estado
- ISBN
- 9780803638204
Acerca de este producto
Product Identifiers
Publisher
Davis Company, F. A.
ISBN-10
0803638205
ISBN-13
9780803638204
eBay Product ID (ePID)
219247248
Product Key Features
Number of Pages
304 Pages
Publication Name
Writing Patient/Client Notes : Ensuring Accuracy in Documentation
Language
English
Publication Year
2016
Subject
Allied Health Services / Occupational Therapy, Medical History & Records, Allied Health Services / Physical Therapy
Type
Textbook
Subject Area
Medical
Format
Trade Paperback
Dimensions
Item Height
0.8 in
Item Weight
24.9 Oz
Item Length
11 in
Item Width
8.5 in
Additional Product Features
Edition Number
5
Intended Audience
College Audience
LCCN
2015-051404
Dewey Edition
22
Illustrated
Yes
Dewey Decimal
615.8/2
Table Of Content
1. Introduction to Documentation I. The Health Record 2. Overview of the Health Record 3. Legal Aspects of the Health Record 4. Reimbursement 5. Reviewing the Health Record as a Physical Therapist II. Documentation Basics 6. Writing in a Health Record 7. Introduction to Note Writing 8. Medical Terminology 9. Using Abbreviations 10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System III. Documenting the Examination 11. The Patient/Client Management Format: Writing History, Including the Review of Systems 12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures 13. The SOAP Note: Stating the Problem 14. The SOAP Note: Writing Subjective (S) , Including the Review of Systems 15. The SOAP Note: Writing Objective (O) IV. Documenting the Evaluation/Assessment (A) 16. Writing the Evaluation / Assessment (A) 17. Writing the Diagnosis (A: DIAGNOSIS) 18. Writing the Prognosis (A: PROGNOSIS) V. Documenting the Plan of Care (P) 19. Writing Expected Outcomes and Anticipated Goals 20. Documenting the Intervention Plan VI. Applications of Documentation Skills 21. Writing the Daily Visit Notes 22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes) 23. Applications and Variations in Note Writing Appendices A. Summary of the Patient/Client Management Note Contents B. Summary of the SOAP Note Contents C. Summary of Contents of the Four Types of Notes D. Tips for Note Writing for Third Party Payers E. Review of Systems and Systems Review Forms
Edition Description
Revised edition,New Edition
Synopsis
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., Master the hows and whys of documentation! Develop all of the skills you need to write clear, concise, and defensiblepatient/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. Section by section you'll learn how to document clearly and accurately, while exercise by exercise you'll practice mastering every step., Addresses how Patient/Client Management and SOAP notes work in accordance with the APTA's Guide to Physical Therapy Practice and WHO's ICF model. Features exercises and worksheets at the end of each section and chapter. Provides samples of both correct and incorrect note writing. Teaches readers how to write a defensible note. Offers a quick review of medical terminology and abbreviations used in note writing., Master the hows and whys of documentation! 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. Section by section you'll learn how to document clearly and accurately, while exercise by exercise you'll practice mastering every step.
LC Classification Number
RM701.6
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