Writing Patient/ Client Notes: Ensuring Accuracy in Documentation

Writing Patient/ Client Notes: Ensuring Accuracy in Documentation

Description:

An ideal resource for any health care professional needing to learn or improve their skills with simple, straightforward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management model. Section by section, exercise by exercise, the 4th Edition will help you to to write clear, concise, and correct patient care notes using a variety of tools, including SOAP notes.

Whats New?

* Five new chapters Writing Evaluation Overview of the Medical Record Legal Issues Reimbursement and The Future: Documentation Using the ICF System.
* An expanded electronic documentation section discusses its challenges and advantages.
* Additional information on how Patient/Client Management and SOAP notes work in accordance with the APTA s Guide to Physical Therapy Practice and the WHO s ICF model.
* Quick reference appendix on the inside back cover, Note Writing and the Process of Clinical Decision-Making.
* An easier-to-use design and clearer text and tables.

Key Features

* Features exercises and worksheets at the end of each section and chapter, with answers provided in Appendix A.
* Provides samples of both correct and incorrect note writing. Teaches readers how to write a defensible note.
* Offers a quick review of medical terminology and abbreviations.

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