Physical Therapy Documentation: From Examination to Outcome, Third Edition

Newly updated and revised, Physical Therapy Documentation: From Examination to Outcome, Third Edition provides physical therapy students, educators, and clinicians with essential information on documentation for contemporary physical therapy practice.

Complete and accurate documentation is one of the most essential skills for physical therapists. In this text, authors Mia L. Erickson, Rebecca McKnight, and Ralph Utzman teach the knowledge and skills necessary for correct documentation of physical therapy services, provide guidance for readers in their ethical responsibility to quality record-keeping, and deliver the mechanics of note writing in a friendly, approachable tone. 

Featuring the most up-to-date information on proper documentation and using the International Classification of Functioning, Disabilities, and Health (ICF) model as a foundation for terminology, the Third Edition includes expanded examples across a variety of practice settings as well as new chapters on: 

• Health informatics
• Electronic medical records
• Rules governing paper and electronic records
• Billing, coding, and outcomes measures

Instructors in educational settings can visit www.efacultylounge.com for additional materials to be used for teaching in the classroom.
An invaluable reference in keeping with basic documentation structure, Physical Therapy Documentation: From Examination to Outcome, Third Edition is a necessity for both new and seasoned physical therapy practitioners. 
 

Contents

Chapter 1: Disablement and Documentation
Chapter 2: Reasons for Documenting in Physical Therapy
Chapter 3: Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation
Chapter 4: Documenting Patient/Client Management: An Overview
Chapter 5: Documentation Formats
Chapter 6: Health Informatics and Electronic Health Records
Chapter 7: Rules for Writing in Medical Records
Chapter 8: Documenting the Examination
Chapter 9: Documenting the Evaluation
Chapter 10: Interim Documentation
Chapter 11: Patient Outcomes and Discharge Summaries
Chapter 12: Documentation, Insurance, and Payment
Abbreviations and Symbols

About the Editors

Mia L. Erickson, PT, EdD, CHT, ATC is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. Mia holds a Bachelor’s Degree from West Virginia University in Secondary Education and a Master's of Science Degree in Physical Therapy from the University of Indianapolis. She earned her doctor of education degree with emphasis in Curriculum and Instruction from West Virginia University. Her clinical practice is in the area of hand and upper extremity rehabilitation.

Ralph R. Utzman, PT, MPH, PhD is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. He holds a Bachelor's Degree in Physical Therapy and a master’s degree in Public Health from West Virginia University, and a PhD in Health Related Sciences from the MCV Campus of Virginia Commonwealth University. His current clinical practice focuses on patients with vestibular disorders and Parkinson's disease. He teaches in the areas of professional practice roles, practice administration, and clinical skills.

Rebecca McKnight, PT, MS received her Bachelor's of Science degree in Physical Therapy from St. Louis University in 1992 and her post-professional Master's of Science degree from Rocky Mountain University of Health Professions in 1999. Rebecca taught in the Physical Therapist Assistant Program at Ozarks Technical Community College in Springfield, MO from 1997 to 2011. Nine of those years she served as Program Director. Currently Rebecca provides consultation related to curriculum design, development, and assessment through her company Reach Consulting. Rebecca is an active member of the American Physical Therapy Association, primarily within the Education Section.