Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy

Ensure confident clinical decisions and maximum reimbursement in a variety of practice settings such as acute care, outpatient, home care, and nursing homes with the only systematic approach to documentation for rehabilitation professionals! Revised and expanded, this hands-on textbook/workbook provides a unique framework for maintaining evidence of treatment progress and patient outcomes with a clear, logical progression. Extensive examples and exercises in each chapter reinforce concepts and encourage you to apply what you’ve learned to realistic practice scenarios.

• A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model ― the one adopted by the APTA.
• Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings.
• Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies ― especially important when insurance companies require evidence of functional progress in order to provide reimbursement.
• Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts.

• NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries.
• UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding.
• EXPANDED number of case examples covers an even broader range of clinical practice areas.