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Book Cover
Author Kettenbach, Ginge.

Title Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach
Edition Fourth edition
Published Philadelphia : F.A. Davis, [2009]


Location Call no. Vol. Availability
Description xiii, 248 pages ; 28 cm
regular print
Contents Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management format : writing history -- The patient/client management format : writing systems review -- The patient/client management format : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S) -- The SOAP note : writing objective (O) -- Writing evaluation -- Writing the diagnosis -- Writing the prognosis -- Writing expected outcomes (long term goals) -- Writing anticipated goals (short term goals) -- Documenting planned interventions -- Overview of the medical record -- Legal aspects of the medical record -- Reimbursement -- Applications and variations in note writing -- Alternatives : documentation forms and computerized documentation -- The future : documentation using the ICF system
Summary Twenty-two chapters cover background information on note taking; documenting the examination, the evaluation, and the plan of care; the medical record; and applications of documental skills. Each chapter includes explanatory text and worksheets; answers are included in the back. The fourth edition contains new chapters on writing evaluation, overview and legal aspects of the medical record, reimbursement, and the future - documentation using the WHO's ICF model
Notes Rev. ed. of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004
Bibliography Includes bibliographical references
Subject Physical therapy -- Documentation -- Problems, exercises, etc.
Occupational therapy -- Documentation -- Problems, exercises, etc.
Medical protocols -- Problems, exercises, etc.
Note-taking -- Problems, exercises, etc.
Genre/Form Problems and exercises.
Author Kettenbach, Ginge. Writing SOAP notes
LC no. 2008030774
ISBN 9780803618787 paperback alkaline paper
0803618786 paperback alkaline paper