Effective Documentation for Physical Therapy Professionals

The content you need to understand every aspect of the documentation process:

Chapter 1. Introduction, Purpose and General Rules for Health Management (Medical Record Keeping) Chapter 2. Record Organization and General Principles Chapter 3. Application of Models for Organization and Guidelines for Content Chapter 4. Component Requirements Chapter 5. Coding and Documentation Chapter 6. Standardized Forms and Content Chapter 7. Legal Issues in the Medical Record Chapter 8. MDS Purpose and Components Chapter 9. Medicare and Non-Medicare Content Principles Chapter 10. Pediatric Documentation Chapter 11. The Electronic Medical Record or Computerized Patient Record Chapter 12. Utilization Review and Utilization Management Appendix A: Abbreviations Appendix B: CMS 700 Form Appendix C: CMS FOrms 1450 and 1500 with Instructions Appendix D: ICD-9 Code Terms Appendix E: APTA Guidelines for Physical Therapy Appendix F: Goal Writing Exercise Appendix G: Note Writing Exercise Appendix H: Documentation Content Exercise Appendix I: Physical Therapy Note Examples

About the Authors

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale.

Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.