Pocket Guide to Therapy Documentation PDF Download
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Author: HCPro
Publisher: HC Pro, Inc.
ISBN: 1601461399
Category : Medical records
Languages : en
Pages : 108
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Book Description
Put documentation tips in the palm of your hand with documentation pocket guides made just for therapists! Proper documentation is vital to reimbursement and patient care in the therapy setting. Improper documentation can lead to a host of problems including denials, decreased reimbursement and lawsuits. Unfortunately, therapists don't receive formal training on documentation and are often left to decipher the confusing requirements set forth by Medicare, Medicaid, and managed care companies, alone. A quick, affordable and convenient tool to address therapy documentation The Pocket Guide to Therapy Documentation offers documentation tips and advice in a convenient and handy format. You'll keep this resource close at hand to ensure complete and accurate patient records. Ensure proper documentation and save time with these benefits: Condensed information and easy-to-read bulleted lists, charts, and tabs for quick reference Fast access to reimbursement and coding information Review documentation requirements in less time for all patient encounters including: Initial examination Evaluation Prognosis Diagnosis Reexamination Discharge Tests and measures Therapy managers in Long-Term Care, home health, and hospital settings will want to purchase one for each Occupational Therapist, Speech Language Pathologist, and Physical Therapist in their facility.
Author: HCPro
Publisher: HC Pro, Inc.
ISBN: 1601461399
Category : Medical records
Languages : en
Pages : 108
Get Book
Book Description
Put documentation tips in the palm of your hand with documentation pocket guides made just for therapists! Proper documentation is vital to reimbursement and patient care in the therapy setting. Improper documentation can lead to a host of problems including denials, decreased reimbursement and lawsuits. Unfortunately, therapists don't receive formal training on documentation and are often left to decipher the confusing requirements set forth by Medicare, Medicaid, and managed care companies, alone. A quick, affordable and convenient tool to address therapy documentation The Pocket Guide to Therapy Documentation offers documentation tips and advice in a convenient and handy format. You'll keep this resource close at hand to ensure complete and accurate patient records. Ensure proper documentation and save time with these benefits: Condensed information and easy-to-read bulleted lists, charts, and tabs for quick reference Fast access to reimbursement and coding information Review documentation requirements in less time for all patient encounters including: Initial examination Evaluation Prognosis Diagnosis Reexamination Discharge Tests and measures Therapy managers in Long-Term Care, home health, and hospital settings will want to purchase one for each Occupational Therapist, Speech Language Pathologist, and Physical Therapist in their facility.
Author: Donald E. Wiger
Publisher: John Wiley & Sons
ISBN: 1119709938
Category : Psychology
Languages : en
Pages : 288
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Book Description
Everything you need to know to record client intake, treatment, and progress—incorporating the latest managed care, accrediting agency, and government regulations Paperwork and record keeping are day-to-day realities in your mental health practice. Records must be kept for managed care reimbursement; for accreditation agencies; for protection in the event of lawsuits; to meet federal HIPAA regulations; and to help streamline patient care in larger group practices, inpatient facilities, and hospitals. The standard professionals and students have turned to for quick and easy, yet comprehensive, guidance to writing a wide range of mental health documents, the Fourth Edition of The Psychotherapy Documentation Primer continues to reflect HIPAA and accreditation agency requirements as well as offer an abundance of examples. Fully updated to include diagnostic criteria of the DSM-5, The Psychotherapy Documentation Primer, 4th Edition is designed to teach documental skills for the course of psychotherapy from the initial interview to the discharge. The documentation principles discussed in the text satisfy the often-rigid requirements of third-party insurance companies, regulating agencies, mental health licensing boards, and federal HIPAA regulations. More importantly, it provides students and professionals with the empirical and succinct documentation techniques and skills that will allow them to provide clear evidence of the effects of mental health treatment while also reducing the amount of their time spent on paperwork.
Author: Mia Erickson
Publisher: SLACK Incorporated
ISBN: 1617110086
Category : Medical
Languages : en
Pages : 176
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Book Description
Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
Author: Rhonda Sutton
Publisher: Createspace Independent Publishing Platform
ISBN: 9781514643587
Category : Counseling
Languages : en
Pages : 156
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Book Description
Dr. Rhonda Sutton's second edition of the straightforward guide to progress notes includes additional examples, information, documentation, and clinical language that expands on the utility and readability of the first book. Additional case studies provide examples of how to use the STEPs to format notes. New chapters include information on clinical language and documentation. This book covers everything about progress notes, from how to write them, to how to store them, and even what to do when someone requests to them. In addition, clinical terms and abbreviations are included as well as suggestions for other clinical documentation such as termination letters, privacy statements, and professional disclosure statements. Suited for all types of mental health clinicians, this book will help therapists improve upon their progress notes and other forms of clinical documentation.
Author: Donald E. Wiger
Publisher: John Wiley & Sons
ISBN: 0470527781
Category : Psychology
Languages : en
Pages : 338
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Book Description
All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.
Author: Cindy Krafft
Publisher: Beacon Health, a Division of Blr
ISBN: 9781615692064
Category : Home care services
Languages : en
Pages : 0
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Book Description
Improve your therapy documentation skills today! This best-selling book has been newly updated to improve therapy documentation immediately. This practical resource is the only product on the market that aids PTs, OTs, and SLPs in honing their documentation skills under OASIS-C and complying with the therapy requirements mandated in the home health PPS rules. Through clear examples, real-life scenarios, and the expertise of author Cindy Krafft, PT, MS, therapists will be able to integrate high-quality documentation processes into effective care management practices. This book will teach you how to: Improve therapy documentation accuracy to ensure payment and compliance Coordinate documentation between therapists and other members of the clinical team to improve patient care Prove medical necessity and need for skilled care by practicing accurate documentation Align documentation with functional reassessment and OASIS-C requirements Prevent missed payment and denials and reduce the risk of an audit Table of Contents: Chapter 1: Welcome to the World of Home Health Chapter 2: Documentation: The "D" Word Chapter 3: Medical Necessity Chapter 4: OASIS: Impact on Therapy Practice Chapter 5: Assessments: The Foundation for Medical Necessity Chapter 6: Goals: Measurable and Meaningful Chapter 7: Planning Care: Putting the Pieces Together Chapter 8: Routine Visits: The Need for Ongoing Therapy Chapter 9: Reassessments: Home Health Requirements Chapter 10: Tips for Qualified Therapists Chapter 11: Tips for Therapist Assistants Chapter 12: Tips for Reviewers Chapter 13: The Future of Therapy in Home Health
Author: Debra Sullivan
Publisher: F.A. Davis
ISBN: 0803629974
Category : Medical
Languages : en
Pages : 301
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Book Description
Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.
Author: Kerryellen Vroman
Publisher: Lippincott Williams & Wilkins
ISBN: 1469832755
Category : Medical
Languages : en
Pages : 478
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Book Description
Fully revised to re flect the latest AOTA standards, Occupational Therapy Evaluation for Adults: A Pocket Guide, 2nd Edition is a quick, comprehensive reference to guide students and practitioners as they perform efficient evaluations of adults, identify problems, and plan and implement interventions to produce optimal therapeutic outcomes. Clinical examples illustrate the application of content, illustrations demonstrate assessment techniques, and extensive tables capture information in an easy-to-read manner. This completely revised and updated Second Edition covers a wide range of new assessments and tools for community-based practitioners, includes up-to-coverage of assessing clients in natural settings, and offers a strong focus on helping readers develop practical skills for the workplace.
Author: Shelley Mulligan
Publisher: Lippincott Williams & Wilkins
ISBN: 1469829436
Category : Children
Languages : en
Pages : 369
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Book Description
"In pediatrics, occupational therapy practitioners are concerned most with positively impacting the extent to children and their families are able to successfully and meaningfully go about their daily lives, whether it be playing, learning, working, caring for oneself or others, or socializing. Clinical decisions made throughout the evaluation process ultimately shape what and how occupational therapy practitioners deliver interventions, perhaps making the evaluation process the most important and interesting part of the service delivery process. It is the context where we first come know and appreciate our clients, their specific situations, and discover what it is that we, as occupational therapy practitioners can do to be of most help"--Provided by publisher.
Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 0323312349
Category : Medical
Languages : en
Pages : 288
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Book Description
Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you’ve learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model — the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies — especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.
