Documentation Basics: A Guide for the Physical Therapist Assistant

Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. Necessary for both students and clinicians, Documentation Basics: A Guide for the Physical Therapist Assistant will teach and explain physical therapy documentation from A to Z.

Documentation Basics: A Guide for the Physical Therapist Assistant covers all of the fundamentals for prospective physical therapist assistants preparing to work in the clinic or clinicians looking to refine and update their skills. Mia Erickson and Becky McKnight have also integrated throughout the text the APTA's Guide to PT Practice to provide up-to-date information on the topics integral for proper documentation.

What's Inside:

• Overview of documentation
• Types of documentation
• Guidelines for documenting
• Overview of the PTA's role in patient/client management, from the patient's point of entry to discharge
• How to write progress notes
• How to use the PT's initial examinations, evaluations, and plan of care when writing progress notes
• Legal matters related to documentation
• Reimbursement basics and documentation requirements

The text also contains a section titled "SOAP Notes Across the Curriculum," or SNAC. This section provides sample scenarios and practice opportunities for PTA students that can be used in a variety of courses throughout a PTA program. These include:

• Goniometry
• Range of motion exercises
• Wound care
• Stroke
• Spinal cord injury
• Amputation

Enter the physical therapy profession confidently withDocumentation Basics: A Guide for the Physical Therapist Assistant by your side.

Doody Review Services

Reviewer:Deborah M. King, PTA, CPI(North Hills Orthopedic and Sports Physical Therapy)
Description:This book provides a comprehensive, well-organized format that can be used by physical therapist assistant (PTA) students, licensed PTAs, and educators.
Purpose:The purpose is to teach PTAs and PTA students the basics of documentation. The book emphasizes the importance of detailed documentation and how this documentation correlates with the role of physical therapy in restoring optimal function to patients. The book clearly outlines the objectives that the PTA or PTA student needs to adhere to when documenting a patient's progress after initial evaluation, through daily notes, to discharge.
Audience:It is geared toward PTA students as well as licensed PTAs. It would be a worthwhile investment for both groups. It also could serve as a review for any PTA, especially one planning a job change to a different rehab setting. It could be used to brush up on the style of progress notes required in a particular clinical setting.
Features:This book covers just about every topic related to documentation, including acceptable formats of documentation, reimbursement issues, and legal and ethical considerations. At the end of each chapter there is an extensive list of review questions and application exercises. The review questions provide a good overview of what is covered in each chapter and the application exercises would be a great study tool for PTA students. Another bonus for the student as well as the PT or PTA professional is Appendix A, which contains a comprehensive list of abbreviations and symbols used in medical documentation.
Assessment:This would be a welcome addition to any PTA curriculum. When in school, students are required to purchase many textbooks that they use once and never open again. This book is something they could leave at the clinic where they work and use periodically for reference.

Mia L. Erickson, PT, EdD, ATC, CHT

Dr. Erickson is the former Program Director of the Physical Therapist Assistant Program at Allegany College of Maryland. Currently she is an Assistant Professor and Co-Academic Coordinator of Clinical Education at West Virginia University. She has a Bachelor’s Degree in Secondary Education and Athletic Training from West Virginia University and a Master of Science Degree in Physical Therapy from the University of Indianapolis. She completed her doctoral work at West Virginia University with emphasis in curriculum and instruction. She maintains clinical practice in the areas of outpatient orthopedics and hand rehabilitation.

Becky McKnight, PT, MS

Ms. McKnight is currently the Program Coordinator of the Physical Therapist Assistant Program at Ozarks Technical Community College. She received a Bachelor’s Degree in Physical Therapy from St. Louis University and a post-professional Master’s Degree in Physical Therapy from Rocky Mountain University of Health Professions. She has also been an Academic Coordinator of Clinical Education at Ozarks Technical Community College. She maintains clinical practice and teaching responsibilities in the areas of neurology and geriatrics.