Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach, Sarah L. Schlomer
Publication details: Philadelphia, PA : F.A. Davis Company, 2016.Edition: Fifth editionDescription: xiii, 279 pages ; 28 cmContent type:- text
- unmediated
- volume
- 9780803638204
- 0803638205
- 615.8/2 23
- RM 701.6 .K487 2016
- 2017 F-805
- WB 18.2
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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