F.A. Davis Company

An ideal resource for any health care professional needing to learn or improve their skills—with simple, straightforward 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 model. Section by section, exercise by exercise, the 4th Edition will help you to to write clear, concise, and correct patient care notes using a variety of tools, including SOAP notes.

• Chapters on Writing Evaluation • Overview of the Medical Record • Legal Issues • Reimbursement • and The Future: Documentation Using the ICF System.
• Expanded electronic documentation section.
• Additional information on how Patient/Client Management and SOAP notes work in accordance with the APTA’s Guide to Physical Therapy Practice and the WHO’s ICF model.
• Features exercises and worksheets at the end of each section and chapter, with answers provided in Appendix A.
• 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.

How to Use This Book

I. Background Information

1. Introduction to Note Writing

2. Writing in a Medical Record

3. Medical Terminology/Worksheets

4. Using Abbreviations/Worksheets

II. Documenting the Examination

5. The Patient/Client Management Format: Writing History/Worksheets

6. The Patient/Client Management Format: Writing Systems Review/Worksheets

7. The Patient/Client Management Format: Documenting Tests and Measures/Worksheets Review Worksheet: Writing the History, Systems Review, and Tests and Measures

8. The SOAP Note: Stating the Problem

9. The SOAP Note: Writing Subjective (S)/Worksheets

10. The SOAP Note: Writing Objective (O)/Worksheets Review Worksheet: Stating the Problem, S & O

III. Documenting the Evaluation (A)

11. Writing Evaluation

12. Writing the Diagnosis

13. Writing the Prognosis/Worksheets Review Worksheet: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis Review Worksheet: Problem, S, O, A VI. Documenting the Plan of Care (P)

14. Writing Expected Outcomes (Long Term Goals)/Worksheets

15. Writing Anticipated Goals (Short Term Goals)/Worksheets

16. Documenting Planned Interventions/Worksheets Final Review Worksheet: Patient/Client Management Note: History, Systems Review, Tests & Measures, Evaluation, Diagnosis, Prognosis, Plan of Care Final Review Worksheet: Problem, S, O, A, P V. The Medical Record

17. Overview of the Medical Record

18. Legal Issues

19. Reimbursement

VI. Applications of Documentation Skills

20. Applications and Variations in Note Writing

21. Alternatives: Documentation Forms and Computerized Documentation

22. The Future: Documentation Using the ICF System

Appendix A: Answers to Worksheets

Appendix B: Summary of the Patient/Client Management Note Contents

Appendix C: Summary of the SOAP Note Contents

Appendix D: Tips for Note Writing for Third Party Payers