Documentation Basics for the Physical Therapist Assistant

Mia L. Erickson, PT, EdD, CHT, ATC, is a faculty member in the Physical Therapy Department at Midwestern University in Glendale, AZ. Mia earned a bachelor’s degree from West Virginia University in secondary education in 1994 and a master of science degree in physical therapy from the University of Indianapolis in 1996. Mia earned a doctoral degree in education from West Virginia University with an emphasis on curriculum and instruction in 2002. Her clinical practice is in the area of hand and upper-extremity rehabilitation. Rebecca McKnight, PT, MS, received her bachelor of science degree in physical therapy from St. Louis University in 1992 and her postprofessional master of science degree from Rocky Mountain University of Health Professions in 1999. She taught at Ozarks Technical Community College for 14 years, serving as Program Director for 9 of those years. Rebecca is an active member of the American Physical Therapy Association and is a former chair of the Physical Therapist Assistant Educators Special Interest Group of the education section. Rebecca has spoken at many national meetings on physical therapist assistant curriculum design and programmatic assessment. She is the 2009 recipient of the F.A. Davis Award for Outstanding Physical Therapist Assistant Educator. Rebecca has been providing educational consultation in the areas of curriculum design, development, and assessment for physical therapist assistant programs nationwide since 2007.

About the Authors Preface Chapter 1 Disablement and Physical Therapy DocumentationChapter 2 The Physical Therapy Episode of Care Chapter 3 Reasons for Documenting Chapter 4 Documentation Formats Chapter 5 Electronic Medical Record Chapter 6 Basic Guidelines for Documentation Chapter 7 Interpreting the Physical Therapist Initial Evaluation Chapter 8 Writing the Subjective Section Chapter 9 Writing the Objective Section Chapter 10 Writing the Assessment and Plan Sections Chapter 11 Payment Basics Chapter 12 Legal and Ethical Considerations for Physical Therapy Documentation Chapter 13 Documentation Across the Curriculum Appendix: Abbreviations and Symbols Index