Physical Therapy Documentation

Mia L. Erickson, PT, EdD, CHT, ATC is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. Mia holds a Bachelor’s Degree from West Virginia University in Secondary Education and a Master's of Science Degree in Physical Therapy from the University of Indianapolis. She earned her doctor of education degree with emphasis in Curriculum and Instruction from West Virginia University. Her clinical practice is in the area of hand and upper extremity rehabilitation. Ralph R. Utzman, PT, MPH, PhD is an associate professor and co-Academic Coordinator of Clinical Education in the Division of Physical Therapy at the West Virginia University School of Medicine. He holds a Bachelor's Degree in Physical Therapy and a master’s degree in Public Health from West Virginia University, and a PhD in Health Related Sciences from the MCV Campus of Virginia Commonwealth University. His current clinical practice focuses on patients with vestibular disorders and Parkinson's disease. He teaches in the areas of professional practice roles, practice administration, and clinical skills. Rebecca McKnight, PT, MS received her Bachelor's of Science degree in Physical Therapy from St. Louis University in 1992 and her post-professional Master's of Science degree from Rocky Mountain University of Health Professions in 1999. Rebecca taught in the Physical Therapist Assistant Program at Ozarks Technical Community College in Springfield, MO from 1997 to 2011. Nine of those years she served as Program Director. Currently Rebecca provides consultation related to curriculum design, development, and assessment through her company Reach Consulting. Rebecca is an active member of the American Physical Therapy Association, primarily within the Education Section.

Chapter 1: Disablement and Documentation Chapter 2: Reasons for Documenting in Physical Therapy Chapter 3: Ethical, Legal, and Regulatory Issues in Physical Therapy Documentation Chapter 4: Documenting Patient/Client Management: An Overview Chapter 5: Documentation Formats Chapter 6: Health Informatics and Electronic Health Records Chapter 7: Rules for Writing in Medical Records Chapter 8: Documenting the Examination Chapter 9: Documenting the Evaluation Chapter 10: Interim Documentation Chapter 11: Patient Outcomes and Discharge Summaries Chapter 12: Documentation, Insurance, and Payment Abbreviations and Symbols