Writing Patient Client Notes: Ensuring Accuracy in Documentation, Fourth Edition

248 Pages·2009·3.52 MB·English

by  Ginge Kettenbach

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Writing
Patient/Client Notes
Ensuring Accuracy in Documentation
4th Edition
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Writing
Patient/Client
Notes
Ensuring Accuracy in
Documentation
4th Edition
Ginge Kettenbach, PhD, PT
Assistant Professor
Saint Louis University
St. Louis, Missouri
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Library of Congress Cataloging-in-Publication Data
Kettenbach,Ginge.
Writing patient/client notes :ensuring accuracy in documentation / Ginge Kettenbach. — 4th ed.
p. ; cm.
Rev. ed. of:Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004.
Includes bibliographical references.
ISBN-13:978-0-8036-1878-7 (pbk. :alk. paper)
ISBN-10:0-8036-1878-6 (pbk. :alk. paper)
1. Physical therapy—Documentation—Problems,exercises,etc. 2. Occupational therapy—Documentation—
Problems,exercises,etc. 3. Medical protocols—Problems,exercises,etc. 4. Note-taking—Problems,exercises,
etc. I. Kettenbach,Ginge. Writing SOAP notes. II. Title.
[DNLM:1. Medical History Taking—Problems and Exercises. 2. Physical Therapy (Specialty)—Problems and
Exercises. 3. Physical Therapy Modalities—Problems and Exercises. 4. Writing—Problems and Exercises. WB
18.2 K43wa 2009]
RM701.6.K48 2009
615.8’2—dc22
2008030774
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Foreword
F
ive years have passed since I last worked on Books are never written or revised without help and
a documentation textbook.At that time,the publication support. I would like to thank the editors at F.A. Davis
was Writing SOAP Notes. As always many things have for their patience and support as I slowly worked on this
happened in the health care environment that have project. My husband, Gerry, always encourages me to
influenced the revision of Writing SOAP Notes into keep going with writing about documentation,although
this text. While the worksheets have stayed, more these projects always require sacrifices from him before I
emphasis has been placed on the Patient/Client Man- complete them. Without Gerry, this book would not
agement note and processes. This was done because exist. I would also like to thank my daughters, Kristen
SOAP notes are becoming less common and have and Kathryn, who have grown up watching me write.
become a method for poor documentation for some They have now left home and still come back to help
therapists. SOAP notes often do not show the thera- cover for me when I write and am too busy to do other
pist’s unique thought processes and do not show things that need to be done in our lives.My final thanks
justification for therapy. go to my colleagues at Saint Louis University, particu-
Many parts of this workbook will look familiar to larly those who have contributed to this book. My
those who have used Writing SOAP Notes in the past. I colleagues in the Department ofHealth Informatics and
decided to keep some form ofSOAP note writing in this Information Management have added three chapters
book for those who will still encounter SOAP notes in about the medical record and reimbursement, areas in
their clinical practice sites.Iftherapists used the form of which they are the true experts. Theresa Bernsen, my
SOAP note in this text that includes the patient/client physical therapy colleague, has written a chapter on
management model,the SOAP note would not be prob- where documentation will likely go in the future.
lematic in documentation. This book is written to help students learn about
As with Writing SOAP Notes, this textbook documentation. What every therapist does is very im-
assumes that the user has access to The Guide to Phys- portant and it is important that what they do is docu-
ical Therapist Practice. It is written as a book that mented well.This book is only a small step in all of the
teaches very new learners how to use the information things that must be learned to become a good therapist.
in The Guide to Physical Therapist Practice for docu- It is my hope that it significantly contributes to the suc-
mentation purposes. cess ofall therapists in their clinical practice.
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Reviewers
Mary Dockter, PT, PhD Susan E. Pivko, PT, DPT, Cert MDT
Assistant Professor and Director of Clinical Education Assistant Professor,Director of Clinical Education
University of Mary Hunter College
Department of Physical Therapy Department of Physical Therapy
Bismarck,ND New York,NY
Lynda Jack, MS, PT Kelly Sass, MPT
Assistant Professor of Physical Therapy Associate,Assistant Academic Coordinator of Clinical
Florida Gulf Coast University Education
Department of Physical Therapy and Human University of Iowa
Performance Graduate Prog in PT and Rehab Science
Ft. Myers,FL Iowa City,IA
Jeffrey Komay, PTA Karen Wingert, DPT/RN
Instructor,ACCE Clinical Associate Professor
Western Technical College University of Missouri
Physical Therapist Assistant Department Department of Physical Therapy
Onalaska,WI Columbia,MO
Carol A. Maritz, Ed.D, PT, GCS Denise Wise, PhD, PT
Assistant Professor of Physical Therapy Chair,Associate Professor
University of the Sciences in Philadelphia The College of St. Scholastica
Department of Physical Therapy Department of Physical Therapy
Narberth,PA Duluth,MN
Kimberly S. Peer, Ed.D, ATC, LAT Benito J. Velasquez, DA, ATC, LAT
Athletic Training Education Program Coordinator, Associate Professor
Associate Professor University of Southern Mississippi
Kent State University School of Human Performance and Recreation
Exercise,Leisure and Sport Hattiesburg,MS
Kent,OH
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Contributors
Theresa G. Bernsen, PT, MA Jody Smith, PhD, RHIA, FAHIMA
Associate Professor Department Chair and Professor
Saint Louis University Department of Health Informatics and Information
Doisy College of Health Sciences Management
Department of Physical Therapy Doisy College of Health Sciences
St. Louis,MO Saint Louis University
St. Louis,MO
Jeanne Donnelly, PhD, RHIA
Associate Professor
Department of Health Informatics and Information
Management
Doisy College of Health Sciences
Saint Louis University
St. Louis,MO
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