a guide to clinical decision making in physical therapy /
Lori Quinn, James Gordon.
Third edition.
Maryland Heights, Missouri :
Elsevier,
[2016]
xiv, 271 pages :
illustrations, portrait ;
28 cm
Includes bibliographical references (pages 222-226) and index.
Key aspects of clinical documentation. Disablement models and the ICF framework -- Essentials of documentation -- Legal aspects of documentation / Helene M. Fearon and Stephen M. Levine -- Standardized outcome measures / Julie Fineman and Lori Quinn -- Payment policy and coding / Helene M. Fearon and Stephen M. Levine -- Electronic medical record / Janet Herbold -- Documenting the initial evaluation and beyond : a case-based guide. Clinical decision making and the initial evaluation format -- Documenting reason for referral : health condition and participation -- Documenting activities -- Documenting impairments in body structure and function -- Documenting the assessment : summary and diagnosis -- Developing and documenting effective goals -- Documenting the plan of care -- Session notes and progress notes using a modified SOAP format -- Special formats : screening evaluations, discharge summaries, letters, and patient education materials -- Documentation in pediatrics / Agnes McConlogue and Lori Quinn.