Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization PDF Download
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Author: Eric Shamus
Publisher: McGraw Hill Professional
ISBN: 1260440672
Category : Medical
Languages : en
Pages : 518
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Book Description
Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important. This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks. With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content. A to Z coverage of physical therapy documentation, including: Documentation Standards and Guidelines Medicare Home Health Electronic Medical Records (EMR) International Classification of Functioning (ICF) Model and Application Pediatrics Legal Issue Utilization Review & Management Skilled Nursing Facilities Sample Documentation Content Initial Examination and Evaluation Criteria Continuum of Care Content and Goal Writing Exercises Documentation Aspects of Supervising PTAs Abbreviations Payment ICD-10 and CPT Codes and Application Chapter Review Questions Content Principles
Author: Eric Shamus
Publisher: McGraw Hill Professional
ISBN: 1260440672
Category : Medical
Languages : en
Pages : 518
Get Book Here
Book Description
Publisher's Note: Products purchased from Third Party sellers are not guaranteed by the publisher for quality, authenticity, or access to any online entitlements included with the product. Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important. This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks. With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content. A to Z coverage of physical therapy documentation, including: Documentation Standards and Guidelines Medicare Home Health Electronic Medical Records (EMR) International Classification of Functioning (ICF) Model and Application Pediatrics Legal Issue Utilization Review & Management Skilled Nursing Facilities Sample Documentation Content Initial Examination and Evaluation Criteria Continuum of Care Content and Goal Writing Exercises Documentation Aspects of Supervising PTAs Abbreviations Payment ICD-10 and CPT Codes and Application Chapter Review Questions Content Principles
Author: Jacqueline A. Osborne
Publisher: Jones & Bartlett Learning
ISBN: 1284105210
Category : Medical
Languages : en
Pages : 278
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Book Description
Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource skillfully explains how to document the interpretation of examination findings so that the medical record accurately reflects the evidence. In addition, the results of consultation with legal experts who specialize in physical therapy claims denials will be shared to provide current, meaningful documentation instruction.
Author: National Academies of Sciences, Engineering, and Medicine
Publisher: National Academies Press
ISBN: 0309377722
Category : Medical
Languages : en
Pages : 473
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Book Description
Getting the right diagnosis is a key aspect of health care - it provides an explanation of a patient's health problem and informs subsequent health care decisions. The diagnostic process is a complex, collaborative activity that involves clinical reasoning and information gathering to determine a patient's health problem. According to Improving Diagnosis in Health Care, diagnostic errors-inaccurate or delayed diagnoses-persist throughout all settings of care and continue to harm an unacceptable number of patients. It is likely that most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences. Diagnostic errors may cause harm to patients by preventing or delaying appropriate treatment, providing unnecessary or harmful treatment, or resulting in psychological or financial repercussions. The committee concluded that improving the diagnostic process is not only possible, but also represents a moral, professional, and public health imperative. Improving Diagnosis in Health Care, a continuation of the landmark Institute of Medicine reports To Err Is Human (2000) and Crossing the Quality Chasm (2001), finds that diagnosis-and, in particular, the occurrence of diagnostic errorsâ€"has been largely unappreciated in efforts to improve the quality and safety of health care. Without a dedicated focus on improving diagnosis, diagnostic errors will likely worsen as the delivery of health care and the diagnostic process continue to increase in complexity. Just as the diagnostic process is a collaborative activity, improving diagnosis will require collaboration and a widespread commitment to change among health care professionals, health care organizations, patients and their families, researchers, and policy makers. The recommendations of Improving Diagnosis in Health Care contribute to the growing momentum for change in this crucial area of health care quality and safety.
Author: Agency for Healthcare Research and Quality/AHRQ
Publisher: Government Printing Office
ISBN: 1587634333
Category : Medical
Languages : en
Pages : 385
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Book Description
This User’s Guide is intended to support the design, implementation, analysis, interpretation, and quality evaluation of registries created to increase understanding of patient outcomes. For the purposes of this guide, a patient registry is an organized system that uses observational study methods to collect uniform data (clinical and other) to evaluate specified outcomes for a population defined by a particular disease, condition, or exposure, and that serves one or more predetermined scientific, clinical, or policy purposes. A registry database is a file (or files) derived from the registry. Although registries can serve many purposes, this guide focuses on registries created for one or more of the following purposes: to describe the natural history of disease, to determine clinical effectiveness or cost-effectiveness of health care products and services, to measure or monitor safety and harm, and/or to measure quality of care. Registries are classified according to how their populations are defined. For example, product registries include patients who have been exposed to biopharmaceutical products or medical devices. Health services registries consist of patients who have had a common procedure, clinical encounter, or hospitalization. Disease or condition registries are defined by patients having the same diagnosis, such as cystic fibrosis or heart failure. The User’s Guide was created by researchers affiliated with AHRQ’s Effective Health Care Program, particularly those who participated in AHRQ’s DEcIDE (Developing Evidence to Inform Decisions About Effectiveness) program. Chapters were subject to multiple internal and external independent reviews.
Author: Martha Bloyer
Publisher: McGraw Hill Professional
ISBN: 1264920105
Category : Medical
Languages : en
Pages : 539
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Book Description
Everything you need to know to perform safe, effective physical therapy on babies, children, and teens Guide to Pediatric Physical Therapy provides pedagogy from top experts in the field to help you master the practice of PT for kids. This dynamic, easy-to-follow resource is filled with cases that help you apply concepts to real world situations, along with art and illustrations that reinforce what you have learned. Each chapter opens with a case, which is followed by two or three additional cases presented as boxed features. Critical information is presented in tables—particularly effective in helping you quickly digest key concepts. With more than 75 collective years teaching pediatric physical therapy, this author team are masters of the subject matter and know how today’s students prefer to learn. • Key tables highlight high-yield information • Each case study is followed by open-ended questions for to consider • Chapter summaries are presented in bullet form to make learning easy and quick • Q/A following summaries are written in NPTE Exam format
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: Elsevier Inc
Publisher: Elsevier Health Sciences
ISBN: 0323681328
Category : Medical
Languages : en
Pages : 259
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Book Description
- NEW! Chapter devoted to cross-cultural communication promotes understanding of care in a diverse workplace - NEW! Chapter on diseases and disorders discusses communication with patients experiencing specific physical and mental illnesses and disorders. - NEW and UNIQUE! Words at Work dialogue boxes demonstrate actual conversations between healthcare workers and clients. - UPDATED! Content reflects the most current communication tools for the modern healthcare setting. - NEW! Full-color design and art program promote engagement. - NEW and UNIQUE! Communication Guidelines boxes direct you to best practices for the effective exchange of information. - NEW! Additional Taking the Chapter to Work case studies demonstrate real-life communication pitfalls and successes.
Author: Julie Pepper
Publisher: Elsevier Health Sciences
ISBN: 0323674763
Category : Medical
Languages : en
Pages : 210
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Book Description
Gain real-world practice with an EHR and realistic, hands-on experience performing EHR tasks! With everything needed to learn the foundations of the EHR process, The Electronic Health Record for the Physician's Office, 3rd Edition, helps you master all the administrative, clinical, and billing/coding skills needed to gain certification — and succeed as a medical office professional. Fully integrated with SimChart for the Medical Office, Elsevier's educational EHR, it walks you through the basics, including implementation, troubleshooting, HIPAA compliance, and claims submissions. This edition contains new and expanded content on patient portals, telehealth, insurance and reimbursement, and data management and analytics, as well as more EHR activities for even more practice. - UNIQUE! Integration with SimChart for the Medical Office, Elsevier's educational EHR (sold separately). - Content and tools prepare you for Certified Electronic Health Records Specialist (CEHRS) certification. - Chapter review activities promote didactic knowledge review and assessment. - Critical thinking exercises threaded within chapters provide thought-provoking questions to enhance learning and stimulate discussion. - EHR exercises with step-by-step instructions are integrated throughout each chapter and build in difficulty to allow for software application. - Trends and Applications boxes help you stay up to date on the industry and the ways in which an EHR can contribute to enhanced health care. - Coverage of paper-based office procedures to aid in transition to EHR. - Application appendices with additional forms allow you to practice applying text content before tackling graded SCMO exercises. - Instructor online resources, including a test bank, TEACH lesson plans and PowerPoint presentations, correlation guides for accreditation and certification, and grading rubrics. - Student online resources with a custom test generator allow for CEHRS exam practice or simulation. - NEW and EXPANDED! New and updated content on telehealth, patient portals, and insurance and reimbursement. - NEW and EXPANDED! EHR activities for hands-on application and practice.
Author: Joseph K. H. Tan
Publisher: Jones & Bartlett Learning
ISBN: 9780834210653
Category : Computers
Languages : en
Pages : 434
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Book Description
This textbook is a logical continuation of Dr. Tan's first book, Healt h Management Information Systems. For graduate level and upper level u ndergraduate courses, it explains the use of health decision support s ystems throughout the health care industry, citing examples from hospi tals, managed care organizations and long term care facilities. This b ook includes learning objectives, case studies and review questions. A n Instructor's guide is also available.
Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 0323312330
Category : Medical
Languages : en
Pages : 289
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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.
