Documentation for Rehabilitation

2nd Edition A Guide to Clinical Decision Making

By Lori Quinn, EdD, PT, Associate Professor, Program in Physical Therapy, New York Medical College, School of Public Health, Valhalla, NY and James Gordon, EdD, PT, Associate Professor and Chair, Department of Biokinesiology and Physical Therapy, University of Southern California, Los Angeles, CA

I. Theoretical Foundations & Documentation Essentials
1. Disablement models, ICF Framework, and Clinical Decision Making
2. Essentials of Documentation
3. Legal Aspects of Documentation - New
4. Clinical Decision Making and the Initial Evaluation Format

II. Components of Physical Therapy Documentation
5. Documenting History: Background Information and Health Condition
6. Documenting History: Participation and Social History
7. Documenting Activities
8. Documenting Impairments in Body Structure and Function
9. Documenting the Assessment: Summary and Diagnosis
10. Documenting Goals
11. Documenting the Plan of Care
12. Daily Notes and Progress Notes using a Modified SOAP Format

III. Additional Documentation Forms
13. Specialized Documentation
14. Documentation in Pediatrics - New
15. Payment Policy and Coding - New
16. Computerized Documentation - New

References
Appendix A. Guidelines for Physical Therapy Documentation
Appendix B. Rehabilitation Abbreviations
Appendix C. Answers to Exercises
Appendix D. Sample Evaluation Forms