Effective Documentation for Physical Therapy Professionals

di Shamus - Stern • 2011 • dettagli prodotto

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DESCRIZIONE

Everything the physical therapists needs to know about the documentation process in one clear, concise, easy-to-follow text. Effective Documentation for Physical Therapy Professionals is your best choice for gaining a solid understanding of the entire physical therapy documentation process. There is no faster or easier way to learn the when, what, and how of physical therapy documentation than this trusted guide. The second edition has been updated to include the most recent professional guidelines, codes, and methodologies and covers timely subjects such as Medicare, electronic record keeping, legal issues, pediatric documentation, utilization review and management, and much more.With Effective Documentation for Physical Therapy Professionals, you will learn how to incorporate all of the general principles of documentation and health information management in order to effectively maintain and organize records, record appropriate information, and receive proper reimbursement based on the documentation content.Table of contentsChapter 1. Introduction, Background, Purpose and General Rules for Health Information Management (Medical Record Keeping) Chapter 2. Record Organization and General Principles Chapter 3. Application of Models for Organization and Guidelines for Content Chapter 4. Content Standardization/Component Requirements Chapter 5. Coding and Documentation Chapter 6. Home Health Documentation Chapter 7. Legal Issues in the Medical Record Chapter 8. MDS Purpose and Components Chapter 9. Medicare and Non-Medicare Content Principles Chapter 10. Pediatric Documentation Chapter 11. The Electronic Medical Record Chapter 12. Utilization Review and Utilization Management Appendix A: Abbreviations Appendix B: CMS 700 Form and CS-1786 HIPPA Disclosure Form Appendix C: CMS Forms 1450 and 1500 with Instructions Appendix D: ICD-9 Code Terms Appendix E: APTA Guidelines for Physical Therapy Documentation and Guidelines for Group Coding Appendix F: Goal Writing Exercise Appendix G: Note Writing Exercise Appendix H: Documentation Content Exercise Appendix I: Documentation Content Examples