Description: Documentation of the treatment process is an important part of any therapeutic regimen. As a record of client care, it provides useful information for the practitioner, other members of the health care team, and third-party payers.

Marcia Stamer has produced a valuable guide to documentation for physical therapists. She describes the S.O.A.P. method of documentation, widely used by doctors and insurance companies. In addition, she demonstrates that dividing notes into subjective, objective, assessment, and plan areas illuminates the clients strengths, problems, and goals, making treatment decisions clearer. Stamer demonstrates that this method can make documentation an effective foundation for treatment.

Explanations and examples of what should and should not be included in each area of documentation, along with exercises for practicing correct documentation, provide the fundamentals every therapist needs. Tips for, documentation shortcuts and suggestions for applying S.O.A.P. methodology to other physical therapy department communications make this book a complete guide to organizing effective communication.

Please Wait