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Book Cover
Author Kettenbach, Ginge.

Title Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach
Edition 4th ed
Published Philadelphia : F.A. Davis, ©2009


Description 1 online resource (248 pages)
Contents Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management note : writing history -- The patient/client management note: writing the systems review -- The patient/client management note : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S) -- The SOAP note : writing objective (O) -- Writing the 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 Suitable for health care professionals needing to learn or improve their skills, this book explains the hows and whys of documentation. It also coves changes in Physical Therapy practice, emphasizing the Patient/Client Management model
Notes Revised edition of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004
Bibliography Includes bibliographical references
Notes Print version record
Subject Physical therapy -- Documentation -- Problems, exercises, etc
Occupational therapy -- Documentation -- Problems, exercises, etc
Medical protocols -- Problems, exercises, etc
Note-taking -- Problems, exercises, etc
Medical history taking.
Physical therapy.
Medical History Taking
Physical Therapy Specialty
Physical Therapy Modalities
writing (processes)
MEDICAL -- Chiropractic.
HEALTH & FITNESS -- Naprapathy.
MEDICAL -- Allied Health Services -- Physical Therapy.
Physical therapy
Medical history taking
Medical protocols
Occupational therapy -- Documentation
Physical therapy -- Documentation
Genre/Form exercise books.
Problems and exercises
Problems and exercises.
Problèmes et exercices.
Form Electronic book
Author Kettenbach, Ginge. Writing SOAP notes
ISBN 9781441636720