Documentation for Rehabilitation : A Guide to Clinical Decision Making in Physical Therapy /
Lori Quinn, James Gordon.
- 4th ed.
- St.Louis, Missouri : Elsevier, 2025.
- 234 p. : 28 cm.
Disablement Models, ICF Framework -- Essentials of Documentation -- Legal Aspects of Documentation -- Standardized Outcome Measures -- Payment Policy and Coding -- Electronic Medical Records -- Clinical Decision Making and the Initial Evaluation Format -- Documenting Reason for Referral : Health Condition and Participation -- Documenting Activities -- Documenting Impairments in Body Structure and Function -- Documenting the Assessment : Summary and Diagnosis -- Develop and Documenting Effective Goals -- Documenting the Plan of Care -- Session Notes and Progress Notes Using a Modified SOAP Format, -- Special Formats: Screening Evaluations, Discharge Summaries, Letters, and Patient Education Materials -- Documentation in Pediatrics