Effective Documentation for Physical Therapy Professionals

Debra F. Stern, DBA, PT is an Assistant Professor of Physical Therapy, College of Allied Health at Nova Southeastern University.

1. Introduction, Purpose and General Rules for Health Management (Medical Record Keeping)

2. Record Organization and General Principles

3. Application of Models for Organization and Guidelines for Content

4. Component Requirements

5. Coding and Documentation

6. Standardized Forms and Content

7. Legal Issues in the Medical Record

8. MDS Purpose and Components

9. Medicare and Non-Medicare Content Principles

10. Pediatric Documentation

11. The Electronic Medical Record or Computerized Patient Record

12. Utilization Review and Utilization Management

References

Appendices

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