Table of Contents

• 1. Introduction to Documentation
• I. The Health Record
• 2. Overview of the Health Record
• 3. Legal Aspects of the Health Record
• 4. Reimbursement
• 5. Reviewing the Health Record as a Physical Therapist
• II. Documentation Basics
• 6. Writing in a Health Record
• 7. Introduction to Note Writing
• 8. Medical Terminology
• 9. Using Abbreviations
• 10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System
• III. Documenting the Examination
• 11. The Patient/Client Management Format: Writing History, Including the Review of Systems
• 12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures
• 13. The SOAP Note: Stating the Problem
• 14. The SOAP Note: Writing Subjective (S), Including the Review of Systems
• 15. The SOAP Note: Writing Objective (O)
• IV. Documenting the Evaluation/Assessment (A)
• 16. Writing the Evaluation / Assessment (A)
• 17. Writing the Diagnosis (A: DIAGNOSIS)
• 18. Writing the Prognosis (A: PROGNOSIS)
• V. Documenting the Plan of Care (P)
• 19. Writing Expected Outcomes and Anticipated Goals
• 20. Documenting the Intervention Plan
• VI. Applications of Documentation Skills
• 21. Writing the Daily Visit Notes
• 22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)
• 23. Applications and Variations in Note Writing
• Appendices
• A. Summary of the Patient/Client Management Note Contents
• B. Summary of the SOAP Note Contents
• C. Summary of Contents of the Four Types of Notes
• D. Tips for Note Writing for Third Party Payers
• E. Review of Systems and Systems Review Forms