THE BEST TEXT FOR MASTERING ALL ASPECTS OF PT DOCUMENTATION
From exercise prescriptions to patient evaluations, insurance forms, billing, and much more—Effective Documentation for Physical Therapy Professionals is your best choice for learning when, what, and how to document. Included are every essential aspect of documentation and many sample documents.
The easy-to-follow format gives you the professional guidelines, codes, and methodology you need to provide expert documentation.
THE FIRST PLACE TO TURN FOR:
*Detailed coverage of every essential aspect of documentation
*Sample documentation content, forms, exercises, and questions
*Examples of “documentation by exception”
*Initial examination and evaluation criteria
*Guidance on writing goals
*Documentation aspects of supervising PTAs and Aides
*SOAP guidelines and examples
Eric Shamus, PhD, PT, CSCS is an Assistant Professor of Physical Therapy and Track Coordinator of the Masters of Medical Science Sports Medicine Program in the College of Allied Health at Nova Southeastern University in Ft. Lauderdale, Florida. He is also an Assistant Professor of Osteopathic Medicine at Nova Southeastern.
Debra F. Stern, DBA, PT is an Assistant Professor of Physical Therapy, College of Allied Health at Nova Southeastern University.
Reviewer:Barbara Jean Billek-Sawhney, PT, EdD, MS, GCS(Slippery Rock University)
Description:This book addresses much more than the what, how and why to document.
Purpose:Based on the title of this book, I thought it would focus on the how of documentation, but it covers much more than documentation and health information management. Topics such as legal issues, utilization review, coding, and the minimum data set are also covered.
Audience:The audience for this book is entry-level clinicians, although I think it would be an asset for entry-level and advanced physical therapy administration courses. It may also serve as a valuable resource for clinicians who change practice settings. The authors and contributors appear to have strong credentials.
Features:The information is presented in 12 chapters and nine appendixes. The foundation for the book is laid in the first, introductory chapter in which the purpose and general rules for health information management, i.e., medical recordkeeping are addressed. Approximately 100 pages of valuable information is provided in the appendixes with note writing and goal writing exercises, samples of notes, ICD-9 codes, various forms for reimbursement, and the APTA Guidelines for PT documentation.
Assessment:This is a valuable book that extends far beyond its title. It is easy to read and understand with nice formatting in the chapters. Each chapter ends with questions related to the material presented. The book would benefit from answers to the end of chapter questions and actual scenarios or examples of how the content is applied in physical therapy practice. This valuable resource will be valued by many readers from entry-level clinicians to experienced practitioners.