Writing Patient/Client Notes: Ensuring Accuracy in Documentation [Paperback]

• Addresses how Patient/Client Management and SOAP notes work in accordance with the APTA’s Guide to Physical Therapy Practice and WHO’s ICF model.
• Features exercises and worksheets at the end of each section and chapter.
• 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 used in note writing.

1. Introduction to Documentation

I. The Health Record
2. Overview of the Health Record
3. Legal Aspects of the Health Record
4. Reimbursement
5. Reviewing the Health Record as a Physical Therapist

II. Documentation Basics
6. Writing in a Health Record
7. Introduction to Note Writing
8. Medical Terminology
9. Using Abbreviations
10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System

III. Documenting the Examination
11. The Patient/Client Management Format: Writing History, Including the Review of Systems
12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures
13. The SOAP Note: Stating the Problem 
14. The SOAP Note: Writing Subjective (S), Including the Review of Systems
15. The SOAP Note: Writing Objectil3¦