Effective documentation for physical therapy professionals

Comprehensive textbook for the documentation course required in all Physical Therapy programs. Covers every aspect of documentation including reimbursement and billing, coding, legal issues, PT and PTA communication, as well as utilization review and quality assurance. Includes a bonus pocket book with sample documentation forms and checklists.

Author Notes

Eric Shamus, PT, PhD, CSCS: Assistant Professor Osteopathic Principles and Practice, College of Osteopathic Medicine, Nova Southeastern University Ft. Lauderdale, Florida
Debra Feingold Stern, PT, MSM, DBA: Assistant Professor of Physical Therapy College of Allied Health Health Professions, Southeastern University Ft. Lauderdale, Florida

Contributors	p. ix
Preface	p. xi
Acknowledgments	p. xiii
Chapter 1 Introduction, Purpose, and General Rules for Health Information Management (Medical Record Keeping)	p. 1
Chapter 2 Record Organization and General Principles	p. 11
Chapter 3 Application of Models for Organization and Guidelines for Content	p. 21
Chapter 4 Component Requirements	p. 33
Chapter 5 Coding and Documentation	p. 43
Chapter 6 Standardized Forms and Content	p. 57
Chapter 7 Legal Issues in the Medical Record	p. 71
Chapter 8 MDS Purpose and Components	p. 91
Chapter 9 Medicare and Non-Medicare Content Principles	p. 103
Chapter 10 Pediatric Documentation	p. 123
Chapter 11 The Electronic Medical Record or Computerized Patient Record	p. 139
Chapter 12 Utilization Review and Utilization Management	p. 153
Pediatric References	p. 177
Appendix A Abbreviations	p. 181
Appendix B CMS 700 Form	p. 197
Appendix C CMS Forms 1450 and 1500 with Instructions	p. 201
Appendix D ICD-9 Code Terms	p. 207
Appendix E APTA Guidelines for Physical Therapy Documentation	p. 211
Appendix F Goal Writing Exercise	p. 229
Appendix G Note Writing Exercise	p. 233
Appendix H Documentation Content Exercise	p. 237
Appendix I Physical Therapy Note Examples	p. 241
Index	p. 253

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