Documentation for Physical Therapist Assistants, 2nd ed. (Reviews of books, computer software, and videotapes are written by invitation).Documentation for Physical Therapist Assistants, ed 2 Lukan M. Philadelphia, Pa 19103, FA Davis Co, 2001, paperback, 208 pp, illus, ISBN ISBN abbr. International Standard Book Number ISBN International Standard Book Number ISBN n abbr (= International Standard Book Number) → ISBN m : 0-8036-0837-3, $25.95. This second edition of Documentation for Physical Therapist Assistants is divided into 2 major sections. The first 3 chapters discuss why physical therapy practitioners document their patient management. The last 7 chapters discuss how to provide documentation. Each chapter begins with learning objectives and ends with review and practice exercises. Chapter 1 presents documentation as evidence of patient care, as a record of the quality of care, as a legal record, and as the basis for reimbursement Reimbursement Payment made to someone for out-of-pocket expenses has incurred. . It traces the evolution of documentation with the changes in physical therapist practice from referral-only to direct access. It also discusses changes in documentation brought about by the enactment of Medicare legislation and subsequent requirements by payers for a higher standard of documentation for reimbursement. Chapter 2 describes the information contained in the medical record. It defines terms as presented in the Guide to Physical Therapist Practice. It also compares the documentation responsibilities of physical therapists and physical therapist assistants. Chapter 3 describes the organization of medical records and the content of the documentation appropriate for inclusion in medical records. It includes brief descriptions of 5 ways to organize information in the medical record: (1) the subjective, objective, assessment, and plans (SOAP) format; (2) problem status plan; (3) problem, status, plan, goals; (4) data, evaluation, performance goals; and (5) functional outcomes reports. This chapter includes actual completed examples of the various record formats, including computerized computerized adapted for analysis, storage and retrieval on a computer. computerized axial tomography see computed tomography. records, flow charts and checklists, Individual Education Plans, Cardex, and standardized standardized pertaining to data that have been submitted to standardization procedures. standardized morbidity rate see morbidity rate. standardized mortality rate see mortality rate. Medicare forms. Chapter 4 presents documentation as the legal record, and it discusses the principles of accuracy, brevity Brevity Adonis’ garden of short life. [Br. Lit.: I Henry IV] bubbles symbolic of transitoriness of life. [Art: Hall, 54] cherry fair cherry orchards where fruit was briefly sold; symbolic of transience. , and clarity as well as how to correct errors. Chapter 5 discusses subjective data and how to determine what is relevant for inclusion in the record as well as organizing and writing the information. Chapter 6 covers objective data and how to organize and record it. It also discusses how to describe the patient's functional level, interventions that are provided to the patient, how to record the physical therapist assistant's objective observations, and common mistakes in recording objective data. As might be expected in a book for physical therapist assistants, chapter 7 is quite brief in its coverage of data interpretation and writing progress notes tied to the evaluation. Chapter 8 discusses the content in the evaluation, and what information is included in the progress notes. This information is presented in order to complete the picture of physical therapy documentation, and it is not meant to instruct in·struct v. in·struct·ed, in·struct·ing, in·structs v.tr. 1. To provide with knowledge, especially in a methodical way. See Synonyms at teach. 2. To give orders to; direct. v. the physical therapist assistant on how to record examination information for the evaluation. Chapter 9 addresses documentation for interventions other than physical therapy. It includes how to record telephone communications, a patient's refusal of intervention, and incident reports. Chapter 10 is a study guide that serves as a quick reference and outline of types of documentation as well as an outline of the content of various sections of the record. This chapter also includes guidelines guidelines, n.pl a set of standards, criteria, or specifications to be used or followed in the performance of certain tasks. and questions that can be asked when critiquing progress notes. The book contains a short bibliography bibliography. The listing of books is of ancient origin. Lists of clay tablets have been found at Nineveh and elsewhere; the library at Alexandria had subject lists of its books. on types of documentation, a glossary A term used by Microsoft Word and adopted by other word processors for the list of shorthand, keyboard macros created by a particular user. See glossaries in this publication and The Computer Glossary. of terms, and a listing of commonly used abbreviations. The author is to be commended for the review questions at the end of each chapter that require the reader to synthesize To create a whole or complete unit from parts or components. See synthesis. information presented in the chapter. The practice exercises in each chapter are extensive and require analysis, rather than a simple, rote rote 1 n. 1. A memorizing process using routine or repetition, often without full attention or comprehension: learn by rote. 2. Mechanical routine. repetition of the book's information by the reader. Overall, this book is a well-written, comprehensive text that may be useful to any physical therapy practitioner--physical therapist assistants and physical therapists alike. Carol Counts Likens, PT, MPA The University of Tennessee Health Science Center Memphis, Term Ms Likens is Director of the Graduate Program in Physical Therapy. Her teaching interests are in the areas of administration, supervision, documentation, and orthopedics orthopedics (ôrthəpē`dĭks), medical specialty concerned with deformities, injuries, and diseases of the bones, joints, ligaments, tendons, and muscles. . |
|
||||||||||||||||||
Printer friendly
Cite/link
Email
Feedback
Reader Opinion