Normal view MARC view ISBD view

Kettenbach, Ginge.

Writing patient/client notes : ensuring accuracy in documentation / Ginge Kettenbach - 4th ed. - 2009 - xiii, 248 pages : illustrations ; 28 cm - 4th ed. .

Rev. ed. of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004

Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management format : writing history -- The patient/client management format : writing systems review -- The patient/client management format : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S). The SOAP note : writing objective (O). Writing evaluation -- Writing the diagnosis -- Writing the prognosis -- Writing expected outcomes (long term goals). Writing anticipated goals (short term goals). Documenting planned interventions -- Overview of the medical record -- Legal aspects of the medical record -- Reimbursement -- Applications and variations in note writing -- Alternatives : documentation forms and computerized documentation -- The future : documentation using the ICF system

ISBN: 0803618786 9780803618787

Subjects--Corporate Names:
Umeå universitet. Miljöarkeologiska laboratoriet.

Subjects--Topical Terms:
Physiotherapy Soap.
Evaluation.
Documentation.
Physical therapy--Documentation
Occupational therapy--Documentation
Medical protocols.
Note-taking.
Physical therapy.
Occupational therapy.

Index Terms--Genre/Form:
Problems and exercises.

LC Class. No.: RM701.6 / .K48 2009