Legal Aspects Of Documenting Patient Care For Rehabilitation Professionals

Because communication among health care professionals can mean the difference between patient life and death, clear and effective patient care documentation is as important as the delivery of care itself. The rehabilitation professional faces formidable documentation responsibilities. Patient care documentation created by the rehabilitation professional must be accurate, comprehensive, concise, objective, and timely. In an interdisciplinary health care environment, documentation must also be expeditiously communicated to other professionals on the health care team.

This Second Edition Of Our Easy-To-Use Reference Takes A Risk Management Approach To Patient Care Documentation. It Shows Clinicians From A Wide Variety Of Disciplines How To Be Objective, Precise, Unambiguous, And Timely When Documenting Treatment-Related Matters. The Content Is Written In Straightforward Lay Language And Includes Sample Documentation Forms. The New Edition Includes Information On Computerized Documentation; Coverage Of Telehealth Issues; Updates On JCAHO, CARF, And NCQA Accreditation; And Documentation Problems Specific To Non-Hospital And Managed Care Settings.

Fourth Edition, is the only text to integrate coverage of the legal responsibilities of rehabilitation professionals with basic, essential advice on how to effectively document patient care activities from intake through discharge. This resource thoroughly covers the basics of documentation and includes many exemplars, cases, and forms, as well as a sample abbreviations used in rehabilitation settings. This book covers all the bases from ethics, to practical aspects of patient care documentation, to relevant and salient legal implications and illustrative case examples that will help students excel in practice.

Although it is the least noticed by patients, effective documentation is one of the most critical skills that speech-language pathologists must learn. With that in mind, Documentation and Reimbursement for Speech-Language Pathologists: Principles and Practiceprovides a comprehensive guide to documentation, coding, and reimbursement across all work settings. The text begins with section 1 covering the importance of documentation and the basic rules, both ethical and legal, followed by an exploration of the various documentation forms and formats. Also included are tips on how to use electronic health records, as well as different coding systems for diagnosis and for procedures, with an emphasis on the link between coding, reimbursement, and the documentation to support reimbursement. Section 2 explains the importance of focusing on function in patient-centered care with the ICF as the conceptual model, then goes on to cover each of the types of services speech-language pathologists provide: evaluation, treatment planning, therapy, and discharge planning. Multiple examples of forms and formats are given for each. In section 3, Nancy Swigert and her expert team of contributors dedicate each chapter to a work setting in which speech-language pathologists might work, whether adult or pediatric, because each setting has its own set of documentation and reimbursement challenges. And since client documentation is not the only kind of writing done by speech-language pathologists, a separate chapter on “other professional writing” includes information on how to write correspondence, avoid common mistakes, and even prepare effective PowerPoint presentations. Each chapter in Documentation and Reimbursement for Speech-Language Pathologists contains activities to apply information learned in that chapter as well as review questions for students to test their knowledge. Customizable samples of many types of forms and reports are also available. Included with the text are online supplemental materials for faculty use in the classroom. Documentation and Reimbursement for Speech-Language Pathologists: Principles and Practice is the perfect text for speech-language pathology students to learn these vital skills, but it will also provide clinical supervisors, new clinicians, and speech-language pathologists starting a private practice or managing a department with essential information about documentation, coding, and reimbursement.

Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation

An excellent introductory guide for healthcare students, this book begins by exploring the current environment of health care and its component parts (professionals, disciplines, organizations, and systems) and proceeds to the concept of

The world of business is ever changing, with much of the available information becoming quickly out-of-date. Business Fundamentals for the Rehabilitation Professional, Second Edition keeps pace with this changing world and provides the health care professional with the latest information to answer the “what, where, how, and when” questions that come up when transforming a health care practice idea into a successful business. With this updated Second Edition, Tammy Richmond and Dave Powers take the health care professional to the next level of implementing successful business operations by the introduction of applications of management principles, as well as implementation of evidence-based practice guidelines and basics to billing and coding documentation. Business Fundamentals for the Rehabilitation Professional, Second Edition addresses how to identify emerging business opportunities, legal and health care regulatory issues, market research and development, and health care operations. New features in the Second Edition: New Management and Operations checklist An in-depth look at reimbursement, billing, and financial survival Strategic target market promotions Updated templates and tools Review questions Downloadable worksheets available with text purchase Keeping the user-friendly format of a workbook, Business Fundamentals for the Rehabilitation Professional, Second Edition is the perfect resource for master and doctorate level students preparing for the professional world, as well as rehabilitation professionals and entrepreneurs interested in obtaining knowledge in starting up, managing, expanding, or understanding the health care practice system. What will you learn? How to create a vision and mission statement How to develop a business and marketing plan How to manage finances within the scope of the practice What are your local state and federal regulations What are the small business guidelines

Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.