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Writing patient/client notes : ensuring accuracy in documentation 5th edition
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| 자료유형 | 단행본 |
|---|---|
| 서명/저자사항 | Writing patient/client notes : ensuring accuracy in documentation/ Ginge Kettenbach, Sarah L. Schlomer. |
| 개인저자 | Kettenbach, Ginge,author. Schlomer, Sarah L.,author, |
| 판사항 | 5th edition. |
| 형태사항 | 1 online resource (xiii, 279 pages): illustrations. |
| 기타형태 저록 | Print version: Kettenbach, Ginge. Writing patient/client notes : ensuring accuracy in documentation. 5th edition. Philadelphia : F.A. Davis Company, [2016] 9780803638204 0803638205 |
| ISBN | 9780803658462 080365846X |
| 서지주기 | Includes bibliographical references and index. |
| 내용주기 | Introduction to documentation -- Part I: The health record. Overview of the health record -- Legal aspects of the health record -- Reimbursement -- Reviewing the health record as a physical therapist -- Part II: Documentation basics. Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the international classification of functioning, disability, and health (ICF) system -- Part III: Documenting the examination. The patient/client management format: writing history, including the review of systems -- The patient/client management format: writing systems review and tests and measures -- The SOAP note: stating the problem -- The SOAP note: writing subjective (S), including the review of systems -- The SOAP note: writing objective (O) -- Part IV: Documenting the evaluation/assessment (A). Writing the evaluation/assessment (A) -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Part V: Documenting the plan of care (P). Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Part VI: applications of documentation skills. Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing -- Appendices. Summary of the patient/client management note contents -- Summary of the SOAP note contents -- Summary of contents of the four types of notes -- Tips for note writing for third-party payors -- Review of systems and systems review forms |
| 일반주제명 | Physical therapy --Documentation --Problems, exercises, etc. Occupational therapy --Documentation --Problems, exercises, etc. Medical protocols --Problems, exercises, etc. Note-taking --Problems, exercises, etc. Medical History Taking. Physical Therapy Modalities. Physical Therapy Specialty. Writing. MEDICAL --Pharmacology. Medical protocols. Note-taking. Occupational therapy --Documentation. Physical therapy --Documentation. |
| 언어 | 영어 |
| 바로가기 |  |
