Documentation for rehabilitation : a guide to clinical decision making /
Lori Quinn, James Gordon
- 2nd ed.
- Maryland Heights, Mo. : Saunders/Elsevier, 2010
- xiv, 263 p. : ill. ; 28 cm.
Rev. ed. of: Functional outcomes documentation for rehabilitation. 2003
Disablement models, ICF framework, and clinical decision making -- Essentials of documentation -- Legal aspects of documentation -- Clinical decision making and the initial evaluation format -- Documenting reason for referral : background information and health condition -- Documenting reason for referral : participation and social history -- Documenting activities -- Documenting impairments in body structure and function -- Documenting the assessment : summary and diagnosis -- Documenting goals -- Documenting the plan of care -- Treatment notes and progress notes using a modified SOAP format -- Specialized documentation -- Documentation in pediatrics / Lori Quinn and Agnes McConlogue -- Payment policy and coding / Helene M. Fearon, Stephen M. Levine, and Lori Quinn -- Computerized documentation / Janet Herbold