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Effective Documentation for Physical Therapy Professionals, 2e

Eric Shamus, Debra Feingold Stern

Preface Copyright Contributors

Chapter 1.	Introduction, Background, Purpose, and General Rules for Health Information Management (Medical Record Keeping)
Chapter 2.	Record Organization and General Principles
Chapter 3.	Application of Models for Organization and Guidelines for Content
Chapter 4.	Content Standardization/Component Requirements
Chapter 5.	Coding and Documentation
Chapter 6.	Home Health Documentation
Chapter 7.	Legal Issues in the Medical Record
Chapter 8.	MDS Purpose and Components
Chapter 9.	Medicare and Non-Medicare Content Principles
Chapter 10.	Pediatric Documentation
Chapter 11.	The Electronic Medical Record
Chapter 12.	Utilization Review and Utilization Management

Appendix A.	Abbreviations
Appendix B.	CMS 700 Form and CS–1786 Hippa Disclosure Form
Appendix C.	CMS Forms 1450 and 1500 with Instructions
Appendix D.	ICD-9 Code Terms
Appendix E.	APTA Guidelines for Physical Therapy Documentation and Guidelines for Group Coding
Appendix F.	Goal Writing Exercise
Appendix G.	Note Writing Exercise
Appendix H.	Documentation Content Exercise
Appendix I.	Documentation Content Examples