Physical Therapy Documentation: From Examination to Outcome

160 Pages·2020·5.04 MB·English

by  Mia Erickson PT EdD CHT ATC, Ralph Utzman PT MPH, Rebecca McKnight PT MS

Physical Therapy
Documentation

Physical Therapy
Documentation
From Examination
to Outcome
Mia L. Erickson, PT, EdD
THIRD EDITION
Certified Hand Therapist
Physical Therapy Department
Midwestern University
Glendale, Arizona
Ralph R. Utzman, PT, MPH, PhD
Professor and Director of Clinical Education
Division of Physical Therapy
West Virginia University School of Medicine
Morgantown, West Virginia
Rebecca S. McKnight, PT, MS
Educational Consultant
Reach Consulting, LLC
Forsyth, Missouri
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Library of Congress Cataloging-in-Publication Data
Names: Erickson, Mia L., author. | Utzman, Ralph, 1966- author. | McKnight,
Rebecca, 1969- author.
Title: Physical therapy documentation : from examination to outcome / Mia
L. Erickson, Ralph R. Utzman, Rebecca S. McKnight.
Description: Third edition. | Thorofare, NJ : SLACK Incorporated, [2020] |
Includes bibliographical references and index.
Identifiers: LCCN 2020006208 | ISBN 9781630916268 (paperback) | ISBN
9781630916275 (epub) | ISBN 9781630916282 (adobe pdf)
Subjects: MESH: Physical Therapy Specialty--organization & administration |
Medical Records | Forms and Records Control
Classification: LCC RM725 | NLM WB 460 | DDC 615.8/2--dc23
LC record available at https://lccn.loc.gov/2020006208
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Last digit is print number: 10 9 8 7 6 5 4 3 2 1
Contents
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
About the Authors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi
Chapter 1 Disablement and Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Mia L. Erickson, PT, EdD
Chapter 2 Reasons for Documenting in Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Mia L. Erickson, PT, EdD
Chapter 3 Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation . . . . . . . . . . . . . . . . . . . 15
Ralph R. Utzman, PT, MPH, PhD
Chapter 4 Documenting Patient/Client Management: An Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Mia L. Erickson, PT, EdD and Rebecca S. McKnight, PT, MS
Chapter 5 Documentation Formats. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Mia L. Erickson, PT, EdD
Chapter 6 Health Informatics and Electronic Health Rec ords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Ralph R. Utzman, PT, MPH, PhD
Chapter 7 Rules for Writing in Medical Rec ords . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Mia L. Erickson, PT, EdD
Chapter 8 Documenting the Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Rebecca S. McKnight, PT, MS and Ralph R. Utzman, PT, MPH, PhD
Chapter 9 Documenting the Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD
Chapter 10 Interim Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD
Chapter 11 Patient Outcomes and Discharge Summaries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
Rebecca S. McKnight, PT, MS and Mia L. Erickson, PT, EdD
Chapter 12 Documentation, Insurance, and Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Ralph R. Utzman, PT, MPH, PhD
Appendix: Abbreviations and Symbols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139

Acknowledgments
I would like to say thank you to Ralph and Becky for continuing to see the need for this text and for supporting
this project. Thank you also for your countless hours of work and contributions. I am also grateful to all the students
who have used this text and allowed me to see areas where we needed to improve. This has kept me accountable for
providing a high-quality product and striving to make it the best textbook for documentation available. To my family,
thank you for allowing me the hours to make this happen.
—Mia L. Erickson, PT, EdD
Thank you to Mia Erickson and Becky McKnight for asking me to join them in writing the first edition all those
years ago. My participation in this project has strengthened my teaching and clinical documentation skills. I also
thank my colleagues and students who have provided helpful feedback and suggestions for the new edition. Finally,
thank you to my family and co-workers for their support.
—Ralph R. Utzman, PT, MPH, PhD
It has indeed been an honor to continue working with Mia and Ralph on this project. I thank them both for the
opportunity. There never is a good time to squeeze in the work necessary to write or revise a textbook, and I appreci-
ate your willingness to shoulder the extra burden and keep this resource available to physical therapy programs and
students.
I also want to thank my husband and my daughter for putting up with me when I cloister myself to work on proj-
ects like this. Thank you for your patience, your support, and your unconditional love.
—Rebecca S. McKnight, PT, MS

About the Authors
Mia L. Erickson, PT, EdD is Professor and Assistant Program Director at Midwestern University in Glendale, AZ.
Mia holds a bachelor’s degree from West Virginia University in Secondary Education and a Master of Science degree
in Physical Therapy from the University of Indianapolis. She earned her Doctor of Education degree with emphasis
in Curriculum and Instruction from West Virginia University. Her clinical practice is in the area of hand and upper
extremity rehabilitation.
Ralph R. Utzman, PT, MPH, PhD is Professor and Director of Clinical Education in the Division of Physical
Therapy at the West Virginia University School of Medicine. He earned his bachelor’s degree in Physical Therapy
and Master of Public Health degree from West Virginia University, and his PhD in Health-Related Sciences from the
Medical College of Virginia campus of Virginia Commonwealth University. His clinical practice focuses on patients
with balance impairments related to vestibular and neurologic movement disorders. He teaches courses in profes-
sional development, health policy, and practice administration. He is a trainer for the American Physical Therapy
Association Credentialed Clinical Instructor Program, Levels 1 and 2.
Rebecca S. McKnight, PT, MS received her Bachelor of Science degree in Physical Therapy from St. Louis University
in 1992 and her post-professional Master of Science degree from Rocky Mountain University of Health Professions
in 1999. Rebecca taught in the Physical Therapist Assistant Program at Ozarks Technical Community College (OTC)
in Springfield, MO, from 1997 to 2011, nine of those years serving as Program Director. Currently, Rebecca provides
consultation to institutions of higher education related to curriculum and instructional design and student and pro-
gram-level assessment through her company Reach Consulting. She also is an adjunct Anatomy instructor for OTC.