Coverart for item
The Resource Writing patient/client notes : ensuring accuracy in documentation, Ginge Kettenbach, Sarah L. Schlomer

Writing patient/client notes : ensuring accuracy in documentation, Ginge Kettenbach, Sarah L. Schlomer

Label
Writing patient/client notes : ensuring accuracy in documentation
Title
Writing patient/client notes
Title remainder
ensuring accuracy in documentation
Statement of responsibility
Ginge Kettenbach, Sarah L. Schlomer
Creator
Contributor
Author
Subject
Genre
Language
eng
Cataloging source
YDXCP
http://library.link/vocab/creatorName
Kettenbach, Ginge
Dewey number
615.8/2
Index
index present
LC call number
RM701.6
Literary form
non fiction
Nature of contents
  • dictionaries
  • bibliography
NLM call number
WB 18.2
http://library.link/vocab/relatedWorkOrContributorName
Schlomer, Sarah L.
http://library.link/vocab/subjectName
  • Physical therapy
  • Occupational therapy
  • Medical protocols
  • Note-taking
  • Medical History Taking
  • Physical Therapy Modalities
  • Physical Therapy Specialty
  • Writing
  • MEDICAL
  • Medical protocols
  • Note-taking
  • Occupational therapy
  • Physical therapy
Label
Writing patient/client notes : ensuring accuracy in documentation, Ginge Kettenbach, Sarah L. Schlomer
Instantiates
Publication
Bibliography note
Includes bibliographical references and index
Carrier category
online resource
Carrier category code
  • cr
Carrier MARC source
rdacarrier
Content category
text
Content type code
  • txt
Content type MARC source
rdacontent
Contents
Introduction to documentation -- Part I: The health record. Overview of the health record -- Legal aspects of the health record -- Reimbursement -- Reviewing the health record as a physical therapist -- Part II: Documentation basics. Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the international classification of functioning, disability, and health (ICF) system -- Part III: Documenting the examination. The patient/client management format: writing history, including the review of systems -- The patient/client management format: writing systems review and tests and measures -- The SOAP note: stating the problem -- The SOAP note: writing subjective (S), including the review of systems -- The SOAP note: writing objective (O) -- Part IV: Documenting the evaluation/assessment (A). Writing the evaluation/assessment (A) -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Part V: Documenting the plan of care (P). Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Part VI: applications of documentation skills. Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing -- Appendices. Summary of the patient/client management note contents -- Summary of the SOAP note contents -- Summary of contents of the four types of notes -- Tips for note writing for third-party payors -- Review of systems and systems review forms
Control code
954270975
Edition
5th edition.
Extent
1 online resource (xiii, 279 pages)
Form of item
online
Isbn
9780803658462
Media category
computer
Media MARC source
rdamedia
Media type code
  • c
Other physical details
illustrations
http://library.link/vocab/ext/overdrive/overdriveId
893bbaa5-941c-4045-ad87-eda71d99c207
Specific material designation
remote
System control number
(OCoLC)954270975
Label
Writing patient/client notes : ensuring accuracy in documentation, Ginge Kettenbach, Sarah L. Schlomer
Publication
Bibliography note
Includes bibliographical references and index
Carrier category
online resource
Carrier category code
  • cr
Carrier MARC source
rdacarrier
Content category
text
Content type code
  • txt
Content type MARC source
rdacontent
Contents
Introduction to documentation -- Part I: The health record. Overview of the health record -- Legal aspects of the health record -- Reimbursement -- Reviewing the health record as a physical therapist -- Part II: Documentation basics. Writing in a health record -- Introduction to note writing -- Medical terminology -- Using abbreviations -- Introduction to documentation using the international classification of functioning, disability, and health (ICF) system -- Part III: Documenting the examination. The patient/client management format: writing history, including the review of systems -- The patient/client management format: writing systems review and tests and measures -- The SOAP note: stating the problem -- The SOAP note: writing subjective (S), including the review of systems -- The SOAP note: writing objective (O) -- Part IV: Documenting the evaluation/assessment (A). Writing the evaluation/assessment (A) -- Writing the diagnosis (A: diagnosis) -- Writing the prognosis (A: prognosis) -- Part V: Documenting the plan of care (P). Writing expected outcomes and anticipated goals -- Documenting the intervention plan -- Part VI: applications of documentation skills. Writing the daily visit note -- The Medicare therapy cap, KX modifiers, and functional limitations reporting (G-codes) -- Applications and variations in note writing -- Appendices. Summary of the patient/client management note contents -- Summary of the SOAP note contents -- Summary of contents of the four types of notes -- Tips for note writing for third-party payors -- Review of systems and systems review forms
Control code
954270975
Edition
5th edition.
Extent
1 online resource (xiii, 279 pages)
Form of item
online
Isbn
9780803658462
Media category
computer
Media MARC source
rdamedia
Media type code
  • c
Other physical details
illustrations
http://library.link/vocab/ext/overdrive/overdriveId
893bbaa5-941c-4045-ad87-eda71d99c207
Specific material designation
remote
System control number
(OCoLC)954270975

Library Locations

    • Ellis LibraryBorrow it
      1020 Lowry Street, Columbia, MO, 65201, US
      38.944491 -92.326012
    • J. Otto Lottes Health Sciences LibraryBorrow it
      1 Hospital Dr, Columbia, MO, 65201, US
      38.939544 -92.328377
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