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Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach, Sarah L. Schlomer

By: Contributor(s): Publication details: Philadelphia, PA : F.A. Davis Company, 2016.Edition: Fifth editionDescription: xiii, 279 pages ; 28 cmContent type:
  • text
Media type:
  • unmediated
Carrier type:
  • volume
ISBN:
  • 9780803638204
  • 0803638205
Subject(s): Genre/Form: DDC classification:
  • 615.8/2 23
LOC classification:
  • RM 701.6 .K487 2016
NLM classification:
  • 2017 F-805
  • WB 18.2
Contents:
Introduction to documentation -- Overview of the health record / Jody Smith -- Legal aspects of the health record / Jody Smith -- Reimbursement / Jody Smith -- Reviewing the health record as a physical therapist -- Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the ICF System / Sarah L. Schlomer, and Theresa Bernsen -- The patient/client management note : writing history, including the review of systems -- The patient/client management note : writing systems review and tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S), including the review of systems worksheet -- The SOAP note: writing objective (O) -- Writing the evaluation -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing.
Summary: "Develop all of the skills you need to write clear, concise, and defensible patient care notes using a variety of tools, including SOAP notes."--Back cover.
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Holdings
Item type Current library Call number Status Date due Barcode
Books Overnight Far Eastern University - Nicanor Reyes Medical Foundation Circulation Section RM 701.6 .K487 2016 c.2 (Browse shelf(Opens below)) Available 0010172
Books Overnight Far Eastern University - Nicanor Reyes Medical Foundation Circulation Section RM 701.6 .K487 2016 (Browse shelf(Opens below)) Available 0009165

Preceded by Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach. 4th ed. 2009.

Includes bibliographical references and index.

Introduction to documentation -- Overview of the health record / Jody Smith -- Legal aspects of the health record / Jody Smith -- Reimbursement / Jody Smith -- Reviewing the health record as a physical therapist -- Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the ICF System / Sarah L. Schlomer, and Theresa Bernsen -- The patient/client management note : writing history, including the review of systems -- The patient/client management note : writing systems review and tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S), including the review of systems worksheet -- The SOAP note: writing objective (O) -- Writing the evaluation -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing.

"Develop all of the skills you need to write clear, concise, and defensible patient care notes using a variety of tools, including SOAP notes."--Back cover.

School of Physical Therapy

SPT-PT Examination and Evaluation

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