Functional Outcomes Documentation for Rehabilitation.

Quinn L, Gordon J. St Louis, MO 63146, Saunders, 2003, paperback, 231 pp, illus, ISBN: 0-7216-8947-7, $29.95.

This text was written to present a framework for clinical reasoning based on the Nagi model of disablement. Although it is a text on documentation, the authors argue that documentation can shape the process of clinical reasoning, and vice versa. The structure used in the book should be familiar to physical therapists who use the Guide to Physical Therapist Practice (Guide) in their teaching and practice. The terms "disability," "functional limitation," "impairment," and "function" take the place of previously used rubrics such as SOAP (subjective, objective, assessment, plans). Guide-friendly langauge and the use of the Guide's patient management model are found throughout.

The first section of the book reviews the theoretical structure for the Nagi disablement model. It then examines the history of physical therapy documentation as well as types of notes and documentation formats. It also illustrates the functional outcomes approach, integrating the patient/client management process with "functional documentation."

In Section II, the authors discuss the examination and evaluation processes in more detail. They provide information on how to gather the history, including background information and medical diagnosis. Documenting elements of disability and social history, functional activities, and specific impairments also is covered. Finally, the book outlines development of the physical therapist's diagnosis, goals for each component of the disablement model (impairment, functional limitation, disability), and intervention plans.

Section III deals with alternative documentation formats. A review of the SOAP note format for progress and daily notes occupies one chapter. Specialized documentation--such as discharge summaries, patient education materials, Medicare documentation, letters of justification, and educational intervention plans for school settings--are summarized. Another chapter deals with automated documentation and its challenges.

Several appendixes provide rich alternative resources. APTA's Guidelines for Physical Therapy Documentation, a list of accepted rehabilitation abbreviations, and sample evaluation forms from various patient settings including the HCFA (Health Care Financing Administration) 700, Outcomes and Assessment Information Set (OASIS), and Inpatient Rehabilitation Facility-Patient Asssessment Instrument (IRF-PAI) are found in these appendixes.

Throughout the book, case studies across all practice settings illuminate the concepts found in each chapter. Ample tables and figures bridge the gap between theory and practice. Wellcrafted learning exercises at the conclusion of each chapter allow practitioners to apply their newly acquired knowledge.

Functional Outcomes Documentation ,for Rehabilitation was originally developed as a leaching tool for students. It achieves this purpose in an admirable fashion. In addition, it is an extremely practical, comprehensive, well-written resource for those attempting to align documentation of clinical practice with tim patient/client management model found in the Guide.

Cynthia Kankel Scott, PT, PhD, MBA 

University of Mississippi Medical (Center

Jackson, Miss

Dr Scott is Associate Professor in the Physical Therapy Department, where she is the Academic Coordinator of Clinical Education and teaches professional development and management courses.