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F. A. Davis Company
Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 5

Writing Patient/Client Notes: Ensuring Accuracy in Documentation / Edition 5

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  • 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.

Product Details

ISBN-13: 9780803638204
Publisher: F. A. Davis Company
Publication date: 05/07/2016
Edition description: Revised
Pages: 288
Sales rank: 567,879
Product dimensions: 8.40(w) x 10.90(h) x 0.80(d)

Table of Contents

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


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

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