Build your documentation skills—and your confidence. Step by step, this text/workbook introduces you to the importance of documentation to support quality patient care and appropriate reimbursement. It shows you how to develop and write a proper and defensible note; and prepares you to meet the technological challenges you’ll encounter in practice.

You’ll learn how to provide the proper documentation to assure all forms of reimbursement (including third party) for your services. You’ll also explore issues of patient confidentiality, HIPAA requirements, and the ever-increasing demands of legal and ethical practice in a litigious society.

I. Reimbursement and Legal Issues Related to Documentation
1.The World Health Organization and the International Classification of Functioning, Disability and Health
2.Demystifying the ICD-10-CM Coding System
3.Your Documentation Related to Legal and Ethical Issues
4.Reimbursement Issues Related to Documentation
5.Physical Therapy Patient Management and Documentation Responsibilities
II.How Do SOAP Notes Ensure Good Patient Care
6.Documentation Content and Organization
7.Introduction to Documentation
8.How Does Documentation Relate to Patient Issues
III.Steps to Documentation 
9.Introduction to the SOAP Note
10.What Are Subjective Data and Why Are They Important?
11.What Are Objective Data and Why Are They Important?
12.What Are Assessment Data and Why Are They Important?
13.What Is the Plan and Why Is It Important?
IV.Testing What You Know
14.Putting the Pieces Together
15.Do You Know Enough?
Bibliography
Glossary
Appendices
A.Abbreviations
B.Soap Note Rubric
C.Documenting Interventions
Index