Writing Patient Client Notes

Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.

Ginge Kettenbach's workbook leads you through the process of learning two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and the Patient/Client Management format. This updated 3rd edition includes hands-on exercises and examples to help you sharpen the writing skills that you will need to prepare clear, concise, and accurate medical documentation. Worksheets at the end of each note section further strengthen your writing skills on the information you have just learned. Explanations of documentation that are consistent with the APTA's Guide to Physical Therapist Practice are given for all decisions. Book jacket.

A one-of-a-kind guide specifically for rehabilitation specialists! A leader in pharmacology and rehabilitation, Charles Ciccone, PT, PhD offers a concise, easy-to-access resource that delivers the drug information rehabilitation specialists need to know. Organized alphabetically by generic name, over 800 drug monographs offer the most up-to-date information on drug indications, therapeutic effects, potential adverse reactions, and much more! A list of implications for physical therapy at the end of each monograph helps you provide the best possible care for your patients. It’s the perfect companion to Pharmacology in Rehabilitation, 4th Edition!

A reference handbook for rehabilitation specialists, featuring many two-color illustrations, tables, and charts. Contains chapters on musculoskeletal, visceral, pulmonary, and vascular anatomy, as well as neuroanatomy, kinesiology, psychology, massage, general medicine, burns, and AIDS, plus useful phrases in Spanish, Italian, French, and German. This second edition is smaller (4.75x8") yet contains one- third more material, with new sections on the ADA, geriatrics, outcome measures, and pharmacology, and offer features enhancing usability, such as section tables of contents and more information on references. Annotation copyrighted by Book News, Inc., Portland, OR

This is the second, revised and expanded edition. The first edition was published under the slightly longer title "How to Take Smart Notes. One Simple Technique to Boost Writing, Learning and Thinking - for Students, Academics and Nonfiction Book Writers". The key to good and efficient writing lies in the intelligent organisation of ideas and notes. This book helps students, academics and other knowledge workers to get more done, write intelligent texts and learn for the long run. It teaches you how to take smart notes and ensure they bring you and your projects forward. The Take Smart Notes principle is based on established psychological insight and draws from a tried and tested note-taking technique: the Zettelkasten. This is the first comprehensive guide and description of this system in English, and not only does it explain how it works, but also why. It suits students and academics in the social sciences and humanities, nonfiction writers and others who are in the business of reading, thinking and writing. Instead of wasting your time searching for your notes, quotes or references, you can focus on what really counts: thinking, understanding and developing new ideas in writing. Dr. Sönke Ahrens is a writer and researcher in the field of education and social science. He is the author of the award-winning book “Experiment and Exploration: Forms of World Disclosure” (Springer). Since its first publication, How to Take Smart Notes has sold more than 100,000 copies and has been translated into seven languages.

The Model Rules of Professional Conduct provides an up-to-date resource for information on legal ethics. Federal, state and local courts in all jurisdictions look to the Rules for guidance in solving lawyer malpractice cases, disciplinary actions, disqualification issues, sanctions questions and much more. In this volume, black-letter Rules of Professional Conduct are followed by numbered Comments that explain each Rule's purpose and provide suggestions for its practical application. The Rules will help you identify proper conduct in a variety of given situations, review those instances where discretionary action is possible, and define the nature of the relationship between you and your clients, colleagues and the courts.

A volume in the Contemporary Perspectives in Rehabilitation Series, curated by Steven L. Wolf, PhD, PT, FAPTA Implement a current, evidence-based approach to the selection, application, and uses of therapeutic modalities as an essential tool for functionally based rehabilitation and as a complement to other types of interventions in a patient-centered model of care. The 7th Edition of this groundbreaking text fosters an in-depth understanding of the science behind each modality, its advantages and limitations, its appropriateness for specific conditions, and its implementation. A hands-on problem-solving approach promotes the development of essential clinical decision-making skills through a wealth of full-color photographs and illustrations, special features, and challenging cases studies. See what students and practitioners are saying about the previous edition… Recommend this book. “Great clinical reference for young therapists and seasoned therapists alike. Great information in a nicely organized book.”—Jane D., Online Reviewer Excellent book “Excellent content. Therapeutic modalities and many more... including spinal decompression devices.”—Online Reviewer

This book provides step-by-step guidelines, tips, and instruction on how to create and write psychotherapy treatment notes. Information and guidance are provided on how to write a treatment intake report, treatment progress notes, and termination summary. A number of sample notes, reports and templates are provided. The book also includes hundreds of representative statements for therapists to use in the design of their own psychotherapy progress notes. A valuable resource for experienced mental health professionals and trainees alike, from the creator of Note Designer therapy note-writing software. ""A time-saving reference to capture the essence and the methods of professional note writing for psychotherapists. Easy to apply and great to keep close-by when writing reports and progress notes."" --Alexandre Smith-Peter, Psy.D. candidate

All the forms, handouts, and records mental health professionals need to meet documentation requirements–fully revised and updated The paperwork required when providing mental health services continues to mount. Keeping records for managed care reimbursement, accreditation agencies, protection in the event of lawsuits, and to help streamline patient care in solo and group practices, inpatient facilities, and hospitals has become increasingly important. Now fully updated and revised, the Fourth Edition of The Clinical Documentation Sourcebook provides you with a full range of forms, checklists, and clinical records essential for effectively and efficiently managing and protecting your practice. The Fourth Edition offers: Seventy-two ready-to-copy forms appropriate for use with a broad range of clients including children, couples, and families Updated coverage for HIPAA compliance, reflecting the latest The Joint Commission (TJC) and CARF regulations A new chapter covering the most current format on screening information for referral sources Increased coverage of clinical outcomes to support the latest advancements in evidence-based treatment A CD-ROM with all the ready-to-copy forms in Microsoft® Word format, allowing for customization to suit a variety of practices From intake to diagnosis and treatment through discharge and outcome assessment, The Clinical Documentation Sourcebook, Fourth Edition offers sample forms for every stage of the treatment process. Greatly expanded from the Third Edition, the book now includes twenty-six fully completed forms illustrating the proper way to fill them out. Note: CD-ROM/DVD and other supplementary materials are not included as part of eBook file.

Accompanying DVD includes videos of the author working with student writers.