[Book Description]

Ginge Kettenbach's workbook leads you through the process of learining two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and the Patient/Client Management format. This updated 3rd edition includes hands-on exercises and examples to help you sharpen the writing skills that you will need to prepare clear concise, and accureate medical documentation. Worksheets at the end of each note section further strengthen your writing skills on the information you have just learned. Explanations of documentation that are consistent with the APTA's Guide to Physical Therapist Practice are given for all decisions.


[Contents]

Foreword
Reviewers
Contents

PART Ⅰ: BACKGROUND INFORMATION
CHAPTER 1. Introduction to Note Writing
CHAPTER 2. Writing in a Medical Record
CHAPTER 3. Medical Terminology
CHAPTER 4. Using Abbreviations

PARTⅡ: DOCUMENTING THE EXAMINATION
CHAPTER 5. The Patient/Client Management Format: History
CHAPTER 6. The Patient/Client Management Format: Writing Systems Review
CHAPTER 7. The Patient/Client Management Format: Documenting Tests and Measures
CHAPTER 8. The SOAP Note: Stating the Problem
CHAPTER 9. The SOAP Note: Writing Subjective (S)
CHAPTER 10. The SOAP Note: Writing Objective

PARTⅢ: DOCUMENTING THE EVALUATION (A)
CHAPTER 11. Writing the Diagnosis Note
CHAPTER 12. Writing the Prognosis

PARTⅣ: DOCUMENTING THE PLAN OF CARE (P)
CHAPTER 13. Writing Expected Outcomes (Long-Term Goals)
CHAPTER 14. Writing Anticipated Goals (Short-Term Goals)
CHAPTER 15. Documenting Planned Interventions

PARTⅤ: APPLICATIONS OF DOCUMENTATION SKILLS
CHAPTER 16. Applications Variations in Note Writing
CHAPTER 17. Alternatives: Documentation Forms, Medicare Forms, and Computerized Documentation

APPENDIX A
APPENDIX B
APPENDIX C
APPENDIX D
APPENDIX E
APPENDIX F