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Subjects
Documentation, Medical history taking, Medical protocols, Note-taking, Occupational therapy, Physical Therapy (Specialty), Physical Therapy Modalities, Physical therapy, Problems and Exercises, Problems, exercises, Writing, Medical History Taking, Physical therapy (specialty), Physical therapy modalities, Problems and exercisesShowing 1 featured edition. View all 1 editions?
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Writing patient/client notes: ensuring accuracy in documentation
2009, F.A. Davis
in English
- 4th ed.
0803618786 9780803618787
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Book Details
Table of 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.
Edition Notes
Rev. ed. of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004.
Includes bibliographical references.
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- Created September 26, 2008
- 13 revisions
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December 19, 2023 | Edited by ImportBot | import existing book |
December 4, 2022 | Edited by ImportBot | import existing book |
December 20, 2020 | Edited by MARC Bot | import existing book |
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September 26, 2008 | Created by ImportBot | Imported from Library of Congress MARC record |