Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource skillfully explains how to document the interpretation of examination findings so that the medical record accurately reflects the evidence. In addition, the results of consultation with legal experts who specialize in physical therapy claims denials will be shared to provide current, meaningful documentation instruction.

Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource skillfully explains how to document the interpretation of examination findings so that the medical record accurately reflects the evidence. In addition, the results of consultation with legal experts who specialize in physical therapy claims denials will be shared to provide current, meaningful documentation instruction.

Four NEW chapters address additional aspects of documentation that rehabilitation professionals will encounter in practice: Legal aspects of documentation Documentation in pediatrics Payment policy and coding Computerized documentation

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.

Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important. This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks. With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content. A to Z coverage of physical therapy documentation, including: Documentation Standards and Guidelines Medicare Home Health Electronic Medical Records (EMR) International Classification of Functioning (ICF) Model and Application Pediatrics Legal Issue Utilization Review & Management Skilled Nursing Facilities Sample Documentation Content Initial Examination and Evaluation Criteria Continuum of Care Content and Goal Writing Exercises Documentation Aspects of Supervising PTAs Abbreviations Payment ICD-10 and CPT Codes and Application Chapter Review Questions Content Principles

- NEW! Updated content throughout the text reflects the current state of primary care and physical therapy practice. - NEW! New chapter on electrodiagnostic testing helps familiarize physical therapists with indications for electrodiagnostic testing and implications of test results to their clinical decision-making. - NEW! New chapter on patients with a history of trauma emphasizes the red flags that physical therapists need to recognize for timely patient referral for appropriate tests. - NEW! Updated information on how to screen and examine the healthy population enhances understanding of the foundations of practice and the role that physical therapists can fill in primary care models.

Written specifically for PTAs! Develop the clinical decision-making skills you need to be a successful PTA. This easy-to-follow approach helps you learn how to successfully relate thermal, mechanical, and electrical biophysical agents to specific therapeutic goals while understanding all the physiologic ramifications. Drawing from the APTA’s Guide to Physical Therapist Practice, this text will enable you to make the connection between a physical agent and the appropriate treatment interventions as part of a comprehensive, successful physical therapy treatment program.