摘要:

One major priority and responsibility of physical therapist educators today is to teach physical therapy students the purposes and the process of documentation. This article reviews the American Physical Therapy Association Documentation Guidelines.1 In addition, it systematically provides educational teaching strategies that assist in the development of documentation skills. Lastly, the article discusses documentation models.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Documentation is the key element of communication between the provider of rehabilitation services and the third-party payer. The third-party payer analyzes documentation through a medical review process to decide if appropriate clinical judgment was used to achieve predictable and reasonable functional outcomes. The impact of health care reform has intensified the need for establishing communication between the rehabilitation provider and the third-party payer to avoid claim denials. This article provides a reviewer's perspective of documentation of rehabilitation services for the geriatric client. Emphasis will be placed on documentation components that are essential to the reviewer for coverage determinations. Identification of inadequacies in documentation and the need for accountability of the rehabilitation provider will be explored.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

Documentation of functional outcomes is crucial for survival in the current health care environment. The clinician is challenged to examine standards of practice to determine if the services provided actually lead to a functional change for the patient. Whether the physical therapist documents balance problems using low technical balance assessments or high technical balance devices, documentation of balance needs to identify intrinsic and extrinsic risk factors, as well as the functional limitations of the patient. Through case study and example, this article demonstrates how to implement these principles.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The trend toward documenting functional outcomes rather than simply describing impairments has been an especially difficult transition for clinicians caring for older adults with wound conditions. Functional outcomes achieved through skilled wound care are greatly influenced by a disciplined decision-making process and the clinician's ability to commit to a plan of care. Documentation is the reflection of this thought process. Documentation may be enhanced by blending concepts inherent to the physiology of normal wound healing with clinical rationale for selected interventions. Once practiced, these principles will greatly assist the clinician to document clearer justification for skilled wound care services and demonstrate positive functional outcomes.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The role and responsibilities of the physical therapist in the skilled nursing facility are continuing to grow. With this growth comes accountability, liability, and responsibility. Documentation serves as the benchmark for the services and interventions provided. This article presents guidelines for and examples of documentation specific to the skilled nursing facility. It reviews some of the documentation requirements of federal and state standards, regulations, and guidelines.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The accreditation process established by the Joint Commission on Accreditation of Healthcare Organizations (Joint Commission) provides a challenge for any health care organization. Supplying documentation to support compliance with the established Joint Commission standards remains a crucial element in achieving accreditation. Recent changes in the standards and survey process obligate the rehabilitation professional to have a working knowledge of the principles of care and documentation required by the Joint Commission.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

摘要:

The purpose of this article is to acquaint readers with the use of computers in documentation and other aspects of clinical practice. Legibility and quality of documentation can be greatly aided by computer technology. Clinical practice can also be aided by computers. Numerous examples are provided to inform readers of various products available for certain tasks.

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID

ISSN:0882-7524    

出版商:OVID    

年代:1997

数据来源: OVID