Writing patient/client notes
Subtitle: ensuring accuracy in documentation
By: Ginge Kettenbach.
Contributors: Kettenbach, Ginge.
Edition: 4th ed.
Publisher: F.A. Davis
Published: 2009
Place of publication: Philadelphia
Language: eng
Number of pages: 256
ISBN-13: 9780803618787
Subjects: Physical therapy -- Documentation -- Problems, exercises, etc; Occupational therapy -- Documentation -- Problems, exercises, etc; Medical protocols -- Problems, exercises, etc; Note-taking -- Problems, exercises, etc; Medical History Taking -- Problems and Exercises; Physical Therapy (Specialty) -- Problems and Exercises; Physical Therapy Modalities -- Problems and Exercises; Writing -- Problems and Exercises
Genres: Problems, exercises, etc.; Problems and Exercises.
Notes: Rev. ed. of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004.

Includes bibliographical references.
Table of contents: title: Introduction to note writing; title: Writing in a medical record; title: Medical terminology; title: Using abbreviations; title: The patient/client management format : writing history; title: The patient/client management format : writing systems review; title: The patient/client management format : documenting tests and measures; title: The SOAP note : stating the problem; title: The SOAP note : writing subjective (S); title: The SOAP note : writing objective (O); title: Writing evaluation; title: Writing the diagnosis; title: Writing the prognosis; title: Writing expected outcomes (long term goals); title: Writing anticipated goals (short term goals); title: Documenting planned interventions; title: Overview of the medical record; title: Legal aspects of the medical record; title: Reimbursement; title: Applications and variations in note writing; title: Alternatives : documentation forms and computerized documentation; title: The future : documentation using the ICF system.