Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization
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Contributors
Preface
Acknowledgements
SECTION 1 How to Write Patient Care Notes
1. Introduction, Background, Purpose, and General Rules for Health Information Management
2. Record Organization and General Principles
3. Application of Models for Organization and Guidelines for Content
4. The Electronic Medical Record
5. Content Standardization and Component Requirements
6. Documentation for Pediatrics
7. Documentation for Home Health
8. Documentation for Certified Nursing Homes
SECTION 2 How to Document Clinical Decision-Making
9. Evidence-Based Practice
10. Clinical Decision-Making
11. Legal Issues in the Medical Record
12. Utilization Review and Utilization Management
SECTION 3 Payment and Coding
13. Coding
14. Documentation Content Principles
15. Alternative Payment Models
SECTION 4 Steps and Framework for Coding and Documentation
16. Documentation Writing Examples and Worksheets
Appendix A Abbreviations
Appendix B OASIS D
Appendix C CMS Form 1500 with Instructions
Appendix D ICD-10 Guidelines
Appendix E APTA Guidelines for Physical Therapy Documentation
Appendix F APTA Documentation Review Checklist
Index
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Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easilyCommunicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important.
This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks.
With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content.
A to Z coverage of physical therapy documentation, including:
- Documentation Standards and Guidelines
- Medicare
- Home Health
- Electronic Medical Records (EMR)
- International Classification of Functioning (ICF) Model and Application
- Pediatrics
- Legal Issue
- Utilization Review & Management
- Skilled Nursing Facilities
- Sample Documentation Content
- Initial Examination and Evaluation Criteria
- Continuum of Care Content and Goal Writing Exercises
- Documentation Aspects of Supervising PTAs
- Abbreviations
- Payment
- ICD-10 and CPT Codes and Application
- Chapter Review Questions
- Content Principles