Writing Patient Client Notes: Ensuring Accuracy in Documentation, Fourth Edition PDF
Preview Writing Patient Client Notes: Ensuring Accuracy in Documentation, Fourth Edition
1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page i Writing Patient/Client Notes Ensuring Accuracy in Documentation 4th Edition 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page ii 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page iii Writing Patient/Client Notes Ensuring Accuracy in Documentation 4th Edition Ginge Kettenbach, PhD, PT Assistant Professor Saint Louis University St. Louis, Missouri 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page iv F. A. Davis Company 1915 Arch Street Philadelphia,PA 19103 www.fadavis.com Copyright ©2009 by F. A. Davis Company Copyright ©2009 by F. A. Davis Company. All rights reserved. This product is protected by copyright. No part of it 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. Printed in the United States of America Last digit indicates print number:10 9 8 7 6 5 4 3 2 1 Acquisitions Editor:Melissa A. Duffield Developmental Editor:Yvonne N. Gillam Manager of Content Development:George W. Lang Publisher:Margaret M. Biblis Art and Design Manager:Carolyn O’Brien As new scientific information becomes available through basic and clinical research,recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate,up to date,and in accord with accepted standards at the time of publication. The author(s),editors, and publisher are not responsible for errors or omissions or for consequences from application of the book,and make no warranty,expressed or implied,in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product informa- tion (package inserts) for changes and new information regarding dose and contraindications before administer- ing any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Kettenbach,Ginge. Writing patient/client notes :ensuring accuracy in documentation / Ginge Kettenbach. — 4th ed. p. ; cm. Rev. ed. of:Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004. Includes bibliographical references. ISBN-13:978-0-8036-1878-7 (pbk. :alk. paper) ISBN-10:0-8036-1878-6 (pbk. :alk. paper) 1. Physical therapy—Documentation—Problems,exercises,etc. 2. Occupational therapy—Documentation— Problems,exercises,etc. 3. Medical protocols—Problems,exercises,etc. 4. Note-taking—Problems,exercises, etc. I. Kettenbach,Ginge. Writing SOAP notes. II. Title. [DNLM:1. Medical History Taking—Problems and Exercises. 2. Physical Therapy (Specialty)—Problems and Exercises. 3. Physical Therapy Modalities—Problems and Exercises. 4. Writing—Problems and Exercises. WB 18.2 K43wa 2009] RM701.6.K48 2009 615.8’2—dc22 2008030774 Authorization to photocopy items for internal or personal use,or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transac- tional Reporting Service,provided that the fee of $.25 per copy is paid directly to CCC,222 Rosewood Drive, Danvers,MA 01923. For those organizations that have been granted a photocopy license by CCC,a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1878 /08 0 (cid:2)$.25. 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page v Foreword F ive years have passed since I last worked on Books are never written or revised without help and a documentation textbook.At that time,the publication support. I would like to thank the editors at F.A. Davis was Writing SOAP Notes. As always many things have for their patience and support as I slowly worked on this happened in the health care environment that have project. My husband, Gerry, always encourages me to influenced the revision of Writing SOAP Notes into keep going with writing about documentation,although this text. While the worksheets have stayed, more these projects always require sacrifices from him before I emphasis has been placed on the Patient/Client Man- complete them. Without Gerry, this book would not agement note and processes. This was done because exist. I would also like to thank my daughters, Kristen SOAP notes are becoming less common and have and Kathryn, who have grown up watching me write. become a method for poor documentation for some They have now left home and still come back to help therapists. SOAP notes often do not show the thera- cover for me when I write and am too busy to do other pist’s unique thought processes and do not show things that need to be done in our lives.My final thanks justification for therapy. go to my colleagues at Saint Louis University, particu- Many parts of this workbook will look familiar to larly those who have contributed to this book. My those who have used Writing SOAP Notes in the past. I colleagues in the Department ofHealth Informatics and decided to keep some form ofSOAP note writing in this Information Management have added three chapters book for those who will still encounter SOAP notes in about the medical record and reimbursement, areas in their clinical practice sites.Iftherapists used the form of which they are the true experts. Theresa Bernsen, my SOAP note in this text that includes the patient/client physical therapy colleague, has written a chapter on management model,the SOAP note would not be prob- where documentation will likely go in the future. lematic in documentation. This book is written to help students learn about As with Writing SOAP Notes, this textbook documentation. What every therapist does is very im- assumes that the user has access to The Guide to Phys- portant and it is important that what they do is docu- ical Therapist Practice. It is written as a book that mented well.This book is only a small step in all of the teaches very new learners how to use the information things that must be learned to become a good therapist. in The Guide to Physical Therapist Practice for docu- It is my hope that it significantly contributes to the suc- mentation purposes. cess ofall therapists in their clinical practice. v 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page vi 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page vii Reviewers Mary Dockter, PT, PhD Susan E. Pivko, PT, DPT, Cert MDT Assistant Professor and Director of Clinical Education Assistant Professor,Director of Clinical Education University of Mary Hunter College Department of Physical Therapy Department of Physical Therapy Bismarck,ND New York,NY Lynda Jack, MS, PT Kelly Sass, MPT Assistant Professor of Physical Therapy Associate,Assistant Academic Coordinator of Clinical Florida Gulf Coast University Education Department of Physical Therapy and Human University of Iowa Performance Graduate Prog in PT and Rehab Science Ft. Myers,FL Iowa City,IA Jeffrey Komay, PTA Karen Wingert, DPT/RN Instructor,ACCE Clinical Associate Professor Western Technical College University of Missouri Physical Therapist Assistant Department Department of Physical Therapy Onalaska,WI Columbia,MO Carol A. Maritz, Ed.D, PT, GCS Denise Wise, PhD, PT Assistant Professor of Physical Therapy Chair,Associate Professor University of the Sciences in Philadelphia The College of St. Scholastica Department of Physical Therapy Department of Physical Therapy Narberth,PA Duluth,MN Kimberly S. Peer, Ed.D, ATC, LAT Benito J. Velasquez, DA, ATC, LAT Athletic Training Education Program Coordinator, Associate Professor Associate Professor University of Southern Mississippi Kent State University School of Human Performance and Recreation Exercise,Leisure and Sport Hattiesburg,MS Kent,OH vii 1878_FM_i-xiv.qxd 1/21/09 11:27 AM Page viii 1878_FM_i-xiv.qxd 1/21/09 11:28 AM Page ix Contributors Theresa G. Bernsen, PT, MA Jody Smith, PhD, RHIA, FAHIMA Associate Professor Department Chair and Professor Saint Louis University Department of Health Informatics and Information Doisy College of Health Sciences Management Department of Physical Therapy Doisy College of Health Sciences St. Louis,MO Saint Louis University St. Louis,MO Jeanne Donnelly, PhD, RHIA Associate Professor Department of Health Informatics and Information Management Doisy College of Health Sciences Saint Louis University St. Louis,MO ix
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