Physical Therapy Documentation: From Examination to Outcome PDF
Preview Physical Therapy Documentation: From Examination to Outcome
Physical Therapy Documentation Physical Therapy Documentation From Examination to Outcome Mia L. Erickson, PT, EdD THIRD EDITION Certified Hand Therapist Physical Therapy Department Midwestern University Glendale, Arizona Ralph R. Utzman, PT, MPH, PhD Professor and Director of Clinical Education Division of Physical Therapy West Virginia University School of Medicine Morgantown, West Virginia Rebecca S. McKnight, PT, MS Educational Consultant Reach Consulting, LLC Forsyth, Missouri Senior Vice President: Stephanie Arasim Portnoy Vice President, Editorial: Jennifer Kilpatrick Vice President, Marketing: Mary Sasso Acquisitions Editor: Tony Schiavo SLACK Incorporated 6900 Grove Road Managing Editor: Allegra Tiver Thorofare, NJ 08086 USA Creative Director: Thomas Cavallaro 856-848-1000 Fax: 856-848-6091 Cover Artist: Katherine Christie www.Healio.com/books Project Editor: Joseph Magaletta © 2020 by SLACK Incorporated Physical Therapy Documentation: From Examination to Outcome, Third Edition includes ancillary materials specifically available for faculty use, including PowerPoint Slides. Please visit http://www.efacultylounge.com to obtain access. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews. The procedures and practices described in this publication should be implemented in a manner consistent with the pro- fessional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Care has been taken to ensure that drug selection and dosages are in accordance with currently accepted/recommended practice. Off-label uses of drugs may be discussed. Due to continuing research, changes in government policy and regulations, and various effects of drug reac- tions and interactions, it is recommended that the reader carefully review all materials and literature provided for each drug, especially those that are new or not frequently used. Some drugs or devices in this publication have clearance for use in a restricted research setting by the Food and Drug and Administration or FDA. Each professional should determine the FDA status of any drug or device prior to use in their practice. Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher. SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide important feedback on the content that we publish. We welcome feedback on this work. Library of Congress Cataloging-in-Publication Data Names: Erickson, Mia L., author. | Utzman, Ralph, 1966- author. | McKnight, Rebecca, 1969- author. Title: Physical therapy documentation : from examination to outcome / Mia L. Erickson, Ralph R. Utzman, Rebecca S. McKnight. Description: Third edition. | Thorofare, NJ : SLACK Incorporated, [2020] | Includes bibliographical references and index. Identifiers: LCCN 2020006208 | ISBN 9781630916268 (paperback) | ISBN 9781630916275 (epub) | ISBN 9781630916282 (adobe pdf) Subjects: MESH: Physical Therapy Specialty--organization & administration | Medical Records | Forms and Records Control Classification: LCC RM725 | NLM WB 460 | DDC 615.8/2--dc23 LC record available at https://lccn.loc.gov/2020006208 For permission to reprint material in another publication, contact SLACK Incorporated. 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Last digit is print number: 10 9 8 7 6 5 4 3 2 1 Contents Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi Chapter 1 Disablement and Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mia L. Erickson, PT, EdD Chapter 2 Reasons for Documenting in Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Mia L. Erickson, PT, EdD Chapter 3 Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation . . . . . . . . . . . . . . . . . . . 15 Ralph R. Utzman, PT, MPH, PhD Chapter 4 Documenting Patient/Client Management: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Mia L. Erickson, PT, EdD and Rebecca S. McKnight, PT, MS Chapter 5 Documentation Formats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Mia L. Erickson, PT, EdD Chapter 6 Health Informatics and Electronic Health Rec ords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Ralph R. Utzman, PT, MPH, PhD Chapter 7 Rules for Writing in Medical Rec ords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 Mia L. Erickson, PT, EdD Chapter 8 Documenting the Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 Rebecca S. McKnight, PT, MS and Ralph R. Utzman, PT, MPH, PhD Chapter 9 Documenting the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD Chapter 10 Interim Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD Chapter 11 Patient Outcomes and Discharge Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD Chapter 12 Documentation, Insurance, and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Ralph R. Utzman, PT, MPH, PhD Appendix: Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139 Acknowledgments I would like to say thank you to Ralph and Becky for continuing to see the need for this text and for supporting this project. Thank you also for your countless hours of work and contributions. I am also grateful to all the students who have used this text and allowed me to see areas where we needed to improve. This has kept me accountable for providing a high-quality product and striving to make it the best textbook for documentation available. To my family, thank you for allowing me the hours to make this happen. —Mia L. Erickson, PT, EdD Thank you to Mia Erickson and Becky McKnight for asking me to join them in writing the first edition all those years ago. My participation in this project has strengthened my teaching and clinical documentation skills. I also thank my colleagues and students who have provided helpful feedback and suggestions for the new edition. Finally, thank you to my family and co-workers for their support. —Ralph R. Utzman, PT, MPH, PhD It has indeed been an honor to continue working with Mia and Ralph on this project. I thank them both for the opportunity. There never is a good time to squeeze in the work necessary to write or revise a textbook, and I appreci- ate your willingness to shoulder the extra burden and keep this resource available to physical therapy programs and students. I also want to thank my husband and my daughter for putting up with me when I cloister myself to work on proj- ects like this. Thank you for your patience, your support, and your unconditional love. —Rebecca S. McKnight, PT, MS About the Authors Mia L. Erickson, PT, EdD is Professor and Assistant Program Director at Midwestern University in Glendale, AZ. Mia holds a bachelor’s degree from West Virginia University in Secondary Education and a Master 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 Professor and Director of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. He earned his bachelor’s degree in Physical Therapy and Master of Public Health degree from West Virginia University, and his PhD in Health-Related Sciences from the Medical College of Virginia campus of Virginia Commonwealth University. His clinical practice focuses on patients with balance impairments related to vestibular and neurologic movement disorders. He teaches courses in profes- sional development, health policy, and practice administration. He is a trainer for the American Physical Therapy Association Credentialed Clinical Instructor Program, Levels 1 and 2. Rebecca S. McKnight, PT, MS received her Bachelor of Science degree in Physical Therapy from St. Louis University in 1992 and her post-professional Master 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 (OTC) in Springfield, MO, from 1997 to 2011, nine of those years serving as Program Director. Currently, Rebecca provides consultation to institutions of higher education related to curriculum and instructional design and student and pro- gram-level assessment through her company Reach Consulting. She also is an adjunct Anatomy instructor for OTC.
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