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Writing patient/client notes : ensuring accuracy in documentation /

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자료유형E-Book
개인저자Kettenbach, Ginge, author.
Schlomer, Sarah L., author.
서명/저자사항Writing patient/client notes :ensuring accuracy in documentation /Ginge Kettenbach, Sarah L. Schlomer.
판사항5th edition.
형태사항1 online resource (xiii, 279 pages) : illustrations
소장본 주기eBooks on EBSCOhostAll EBSCO eBooks
ISBN9780803658462
080365846X


서지주기Includes bibliographical references and index.
내용주기Introduction 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
일반주제명Physical 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.
언어영어
기타형태 저록Print version:Kettenbach, Ginge.Writing patient/client notes : ensuring accuracy in documentation.5th edition.Philadelphia : F.A. Davis Company, [2016]97808036382040803638205
대출바로가기http://search.ebscohost.com/login.aspx?direct=true&scope=site&db=nlebk&AN=1290529

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