Communicating Clinical Decision-Making Through Documentation: Coding, Payment, and Patient Categorization

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Clear, concise, and simple to follow—everything you need to master the documentation process quickly and easily


Communicating Clinical Decision Making Through Documentation is the top choice for professionals and students seeking complete coverage of the documentation process including billing and coding. It shows how to ensure every service rendered and billed is supported by showing what to document, how to do it, and why it is so important.


This text includes a refreshing student-friendly approach to the topic. You will find an abundance of cases portraying real-life case scenarios and it delivers must-know information on writing patient/client care notes, incorporating document guidelines, documenting clinical decision making (includes evidence-based practice), and performing billing and coding tasks.


With Communicating Clinical Decision Making Through Documentation, you’ll effectively maintain and organize records, record appropriate information, and receive proper payment based on the documentation content.


A to Z coverage of physical therapy documentation, including:
Documentation Standards and Guidelines

Medicare

Home Health

Electronic Medical Records (EMR)

International Classification of Functioning (ICF) Model and Application

Pediatrics

Legal Issue

Utilization Review & Management

Skilled Nursing Facilities

Sample Documentation Content

Initial Examination and Evaluation Criteria

Continuum of Care Content and Goal Writing Exercises

Documentation Aspects of Supervising PTAs

Abbreviations

Payment

ICD-10 and CPT Codes and Application

Chapter Review Questions

Content Principles