Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

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Clear, concise, and simple to follow―everything you need to master the documentation process quickly and easily

Communicating 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
  
  
  
  
  
  

Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

William McGehee, P.T. is the Director of Physical Therapy at the University of Florida and an active member of the American Academy of Physical Therapy (AAPT).

Debra F. Stern, PT, MSM, DBA, is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department.