Documentation Basics

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. Necessary for both students and clinicians, Documentation Basics: A Guide for the Physical Therapist Assistant will teach and explain physical therapy documentation from A to Z. Documentation Basics: A Guide for the Physical Therapist Assistant covers all of the fundamentals for prospective physical therapist assistants preparing to work in the clinic or clinicians looking to refine and update their skills. Mia Erickson and Becky McKnight have also integrated throughout the text the APTA's Guide to PT Practice to provide up-to-date information on the topics integral for proper documentation. What's Inside: Overview of documentation Types of documentation Guidelines for documenting Overview of the PTA's role in patient/client management, from the patient's point of entry to discharge How to write progress notes How to use the PT's initial examinations, evaluations, and plan of care when writing progress notes Legal matters related to documentation Reimbursement basics and documentation requirements The text also contains a section titled "SOAP Notes Across the Curriculum," or SNAC. This section provides sample scenarios and practice opportunities for PTA students that can be used in a variety of courses throughout a PTA program. These include: Goniometry Range of motion exercises Wound care Stroke Spinal cord injury Amputation Enter the physical therapy profession confidently with Documentation Basics: A Guide for the Physical Therapist Assistant by your side.

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Third Edition of Documentation Basics 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 Third Edition to reflect changes in the ever-evolving profession. Newly addressed are the changes in documentation requirements for major payers, changes in the disablement models used, and the increasingly common use of electronic documentation in the physical therapy profession. Features inside the Third Edition: Readers are encouraged to think about disablement and disablement concepts when writing notes How to document impairments in body structure and function but more importantly activity limitations and participation restriction Descriptions of the differences in documentation methods using a computer vs paper chart Evidence tied to benefits and challenges of computerized documentation Documenting the rationale for treatment and the unique skills of the physical therapist assistant in patient management New inside the Third Edition: Incorporation of the International Classification of Functioning, Disability, and Health disablement model Chapter on electronic documentation Screenshot examples of the popular WebPT® electronic medical record platform Updated chapters on reimbursement and legal issues Additional examples for student practice included in each chapter Included with the text are online supplemental materials for faculty use in the classroom. Documentation Basics for the Physical Therapist Assistant, Third 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.

The documentation system described in this text is designed to support Good Manufacturing Practices (GMP) in a medical manufacturing environment. However, the usefulness of the system can be extended to other areas of a corporation (development, clinicals, marketing, finance, as well as to many other unrelated, nonmedical industries). The principles & the decision making inherent in documentation system design remain the same, no matter what the product or business. The book describes the creation, use & control of the descriptive documents, data collection documents, numbering systems & data files that are appropriate for use in an industry subject to Good Manufacturing Practices. The text was written as a guideline for the individuals who must design the systems & work with them routinely. The descriptive documents presented in this book are designed to serve two purposes: to direction task-specific events & to educate the reader about the event in a manner that supports responsible decision making. It presents the major components of a GMP documentation system, gives examples of design, format & content, & explains how these components interact. $US42.95 plus shipping & tax where applicable. Call or write Advanstar Communications, Marketing Services; 7500 Old Oak Boulevard; Cleveland, OH 44130. 216-826-2839 or 800-598-6008.

This biannual offers detailed coverage of the regulations, requirements, and techniques for the validation of processes and systems used in regulated international industries. It addresses significant requirements for pharmaceutical, medical device, and biologic companies as well as environmental laboratories. It examines Good Manufacturing Principles (GMPs), Good Clinical Practices (GCPs), Good Laboratory Practices (GLPs), Good Automated Library Practices (GALPs), and others, and elucidates up-to-the-minute industry changes and international concerns.

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions. New in the Fifth Edition: Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents Updated information to meet Medicare Part B and other third-party payer requirements Revised clinical terminology on par with current trends Added examples from emerging practice areas Expanded tables along with new worksheets and learning activities Included with the text are online supplemental materials for faculty use in the classroom, this includes: access to supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.

Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice. Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone. Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on: Health informatics Electronic medical records Rules governing paper and electronic records Billing, coding, and outcomes measures Included with the text are online supplemental materials for faculty use in the classroom. An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners.

This balanced examination of ethical and legal principles and issues provides vital information for radiography, ultrasound, nuclear medicine, and radiation professionals. By discussing the foundations of ethics for technologists, then entering into a discussion of applicable law, Ethical and Legal Issues for Imaging Professionals, 2nd Edition provides an approach that leads to a more successful style of personal risk management. With each chapter divided into two sections of ethical issues and legal issues, the content is easy to read and understand. Plus, learning activities and current event discussions help the readers learn and remember information so they can use it in real life. Imaging Scenarios spark classroom discussion and encourage students to apply what they have learned and develop critical thinking and problem solving skills. Review Questions at the end of each chapter allow students to test their retention of chapter content. Critical Thinking Questions and Activities helps students examine their personal responses to various situations and encourages them to expand on their knowledge of policies and procedures. Professional Profiles present a brief glimpse into how ethics and law impact the daily lives of professional imaging technologists. Margin Definitions and Glossary provide an easily accessible resource to understanding terminology. Learning Objectives and Chapter Outline focus the student on the most important content. Discussion of limited radiographers, health care literacy, HIPAA, employee rights, whistle blowing, and relevant new technologies include the most current information available to keep readers up-to-date on topics in their field. More relevant and up-to-date case studies keep readers current on situations they may face in the field. Expanded content on the history of ethics gives users a better understanding of ethics. Updated legal terminology provides the most current information on the ever-changing world of law. Bulleted key point summaries highlight important information from each chapter for easy review.

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.