Table Of Content6114_FM_i-xvi 30/06/17 11:47 am Page i
Documentation
for Physical Therapist
Assistants
FIFTH EDITION
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Wendy D. Bircher, PT, EdD
Retired Program Director/Professor
San Juan College
Farmington, New Mexico
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Library of Congress Cataloging-in-Publication Data
Names: Bircher, Wendy D., author.
Title: Documentation for physical therapist assistants / Wendy D. Bircher.
Description: Fifth edition. | Philadelphia : F.A. Davis Company, [2018] |
Includes bibliographical references and index.
Identifiers: LCCN 2017014875 | ISBN 9780803661141
Subjects: | MESH: Forms and Records Control—methods | Physical Therapy
Modalities—organization & administration | Physical Therapist Assistants
| Medical Records—standards
Classification: LCC RM705 | NLM WB 460 | DDC 615.8/2—dc23
LC record available at https://lccn.loc.gov/2017014875
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To my husband, John, for your patience, love, friendship, and humor.
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Preface
The physical therapy profession continues to evolve with new research in clinical practice,
changes in documentation procedures with the introduction of electronic health records,
changes in insurance reimbursement, and coding with the initiation of the ICD-10 system. One
of the most significant changes came with the introduction of the physical therapist assistant
(PTA). With that introduction, there became a need to provide educational programming to en-
able our profession to bring the standards of care for patient treatment into the 21st century.
Along with the development of additional PTA educational programs in 4-year educational in-
stitutions and community colleges, textbooks at the PTA level became essential. F.A. Davis’s
vision continues to ensure that the development of such textbooks remains available in a timely
fashion. Along with the development of textbooks specific to the PTA student, ancillary support
was also necessary for educators in PTA programs. F.A. Davis has also met that challenge.
Having practiced for more than 41 years in the pediatric, home health, outpatient, and re-
habilitation settings, I have found that the changes in documentation, over time, have made it
difficult for many therapists to keep current with third-party payers and their individual and
specific requirements. After teaching in a PTA program for 16 years, I found that instruction
in documentation is vital for the PTA student to develop suitable documentation skills and then
to transfer those skills into the clinical setting, ensuring proper documentation that supports
quality patient care and appropriate reimbursement.
In addition to becoming familiar with the revisions presented in this new edition, the PTA,
along with the PT, must keep abreast of new developments in documentation, as outlined in
APTA’s Guide to Physical Therapist Practice(revised 2014) and the impact of the World Health
Organization’s International Classification of Functioning, Disability, and Health (ICF) on
proper documentation and reimbursement for patient care. Information included in the Guide
to Physical Therapist Practiceprovides the PTA student with essential information related to
ethical practice, appropriate documentation techniques, and general guidelines for PTA super-
vision in any treatment setting. The Guidecontinues to be a valuable and necessary resource
for any PT or PTA practicing in today’s clinical setting.
With the implementation of the ICD-10 coding and billing system on October 1, 2015,
which replaced the ICD-9 coding system, additional and updated changes were needed in this
edition of this textbook to address those changes. For that purpose, a new chapter was added
to address the initiation of the ICD-10, not because PTAs will be responsible for billing but in-
stead to provide an understanding of that process when treating their patients. In addition, mul-
tiple reviewers have requested information be included in this revision related to electronic
health records (EHR), issues related to the Commission on Accreditation in Physical Therapy
Education (CAPTE), clinical performance evaluation in the clinical setting, and the differences
between education provided for the PT versus the PTA. While these issues remain paramount
to the education of the profession, it is not the purpose of this textbook to discuss the function-
ality of these issues. The main purpose of this textbook continues to be providing the informa-
tion inherent in the content of the documentation process provided when treating patients
receiving skilled physical therapy care, whether that information is collected on paper or in
electronic form. It is hoped that the additional content that was requested is provided through
the use of other textbooks, through the use of the online material provided by the American
Physical Therapy Association (APTA), and through the mentorship provided in the educational
and clinical settings.
For those educational programs that would like more information on the use of documen-
tation and EHR, F.A. Davis provides a CD for programs to practice adding information in an
example of an EHR. Also new to this edition and included on the instructor disk are multiple
case studies that can be used in the educational setting. The case studies address multiple types
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viii Preface
of diagnoses within different clinical settings, and the instructor may use them in any way he or
she chooses. Instructors are also reminded that the answers to all of the review and practice exer-
cises are included in the instructor information and can be printed for student use and review.
While we will continue to address an ever-changing scenario for the provision of health-
care services in the years to come, it is hoped that this textbook will provide those taking the
journey with the skills to map their route with confidence.
—Wendy Bircher
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Reviewers
DENISE ABRAMS, PT, DPT, MA LINDA J. JOHNSON, PT, MS
Chairperson Academic Coordinator of Clinical Education
Physical Therapist Assistant Program CACHE PTA Program
SUNY Broome Community College Anne Arundel Community College
Binghamton, New York Arnold, Maryland
TAWNY CHAMBERLAIN, PT, DPT JACKI KLACZAK KOPACK, PT, DPT
Program Director PTA Program Director
Physical Therapist Assistant Program PTA Program
South University Harcum College
Glen Allen, Virginia Bryn Mawr, Pennsylvania
JILL DZIAK, PTA, CBIS, MEd TAMMY MARCIN, PT, DPT, MBA
Adjunct Faculty Chair
Health and Sciences Physical Therapist Assistant Program
College of DuPage Horry Georgetown Technical College
Glen Ellyn, Illinois Conway, South Carolina
GABRIELLA M. FERREIRA, BS, PTA BETTY T. SALAS, PT, DPT
Instructor Physical Therapist Assistant
PTA Program Wharton County Junior College
Harcum College Wharton, Texas
Bryn Mawr, Pennsylvania
ADAM J. THOMPSON, PhD, LAT, ATC
COSETTE HARDWICK, PT, DPT Professor
Associate Professor Health and Human Performance
Department of Nursing and Allied Health Indiana Wesleyan University
Missouri Western State University Marion, Indiana
St Joseph, Missouri
PATRICIA HOOKER, PTA, MA
Associate Professor
PTA Program, Health Sciences
College of Central Florida
Ocala, Florida
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