Writing Patient / Client Notes: Ensuring Accuracy in Documentation

Master the hows and whys of documentation!

Develop all of the skills you need to write clear, concise, and defensiblepatient/client care notes using a variety of tools, including SOAP notes.

This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

Section by section you’ll learn how to document clearly and accurately, while exercise by exercise you’ll practice mastering every step.

1. Introduction to Documentation

I. The Health Record
2. Overview of the Health Record
3. Legal Aspects of the Health Record
4. Reimbursement
5. Reviewing the Health Record as a Physical Therapist

II. Documentation Basics
6. Writing in a Health Record
7. Introduction to Note Writing
8. Medical Terminology
9. Using Abbreviations
10. Introduction to Documentation Using the International Classification of Functioning, Disability, and Health (ICF) System

III. Documenting the Examination
11. The Patient/Client Management Format: Writing History, Including the Review of Systems
12. The Patient/Client Management Format: Writing Systems Review and Tests and Measures
13. The SOAP Note: Stating the Problem 
14. The SOAP Note: Writing Subjective (S), Including the Review of Systems
15. The SOAP Note: Writing Objective (O)

IV. Documenting the Evaluation/Assessment (A)
16. Writing the Evaluation / Assessment (A)
17. Writing the Diagnosis (A: DIAGNOSIS)
18. Writing the Prognosis (A: PROGNOSIS)

V. Documenting the Plan of Care (P)
19. Writing Expected Outcomes and Anticipated Goals
20. Documenting the Intervention Plan

VI. Applications of Documentation Skills
21. Writing the Daily Visit Notes
22. The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G Codes)
23. Applications and Variations in Note Writing

Appendices
A. Summary of the Patient/Client Management Note Contents
B. Summary of the SOAP Note Contents
C. Summary of Contents of the Four Types of Notes
D. Tips for Note Writing for Third Party Payers
E. Review of Systems and Systems Review Forms