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Writing Patient/Client Notes


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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

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Item ships from and is sold by Fishpond World Ltd.
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