Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale. Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

• ContentsContributorsPrefaceAcknowledgementsSECTION 1 How to Write Patient Care Notes1. Introduction, Background, Purpose, and General Rules for Health Information Management2. Record Organization and General Principles3. Application of Models for Organization and Guidelines for Content4. The Electronic Medical Record5. Content Standardization and Component Requirements6. Documentation for Pediatrics7. Documentation for Home Health8. Documentation for Certified Nursing HomesSECTION 2 How to Document Clinical Decision-Making9. Evidence-Based Practice10. Clinical Decision-Making11. Legal Issues in the Medical Record12. Utilization Review and Utilization ManagementSECTION 3 Payment and Coding13. Coding14. Documentation Content Principles15. Alternative Payment ModelsSECTION 4 Steps and Framework for Coding and Documentation16. Documentation Writing Examples and WorksheetsAppendix A AbbreviationsAppendix B OASIS DAppendix C CMS Form 1500 with InstructionsAppendix D ICD-10 GuidelinesAppendix E APTA Guidelines for Physical Therapy DocumentationAppendix F APTA Documentation Review ChecklistIndex

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale. Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

• ContentsContributorsPrefaceAcknowledgementsSECTION 1 How to Write Patient Care Notes1. Introduction, Background, Purpose, and General Rules for Health Information Management2. Record Organization and General Principles3. Application of Models for Organization and Guidelines for Content4. The Electronic Medical Record5. Content Standardization and Component Requirements6. Documentation for Pediatrics7. Documentation for Home Health8. Documentation for Certified Nursing HomesSECTION 2 How to Document Clinical Decision-Making9. Evidence-Based Practice10. Clinical Decision-Making11. Legal Issues in the Medical Record12. Utilization Review and Utilization ManagementSECTION 3 Payment and Coding13. Coding14. Documentation Content Principles15. Alternative Payment ModelsSECTION 4 Steps and Framework for Coding and Documentation16. Documentation Writing Examples and WorksheetsAppendix A AbbreviationsAppendix B OASIS DAppendix C CMS Form 1500 with InstructionsAppendix D ICD-10 GuidelinesAppendix E APTA Guidelines for Physical Therapy DocumentationAppendix F APTA Documentation Review ChecklistIndex

Eric Shamus, DPT, PhD, CSCS has taught national and international continuing education courses on Orthopeadics, Sports Medicine, and Manual Therapy, with a focus on documentation and reimbursement. He is presently a professor at Florida Gulf Coast University and works at an outpatient orthopedic facility in Fort Lauderdale. Debra F. Stern, PT, MSM, DBA is an Associate Professor at Nova Southeastern University in Fort Lauderdale, FL. She serves as a clinical instructor with a focus on geriatrics, neuromuscular disorders, and also coordinates service learning experiences for the school's PT department. She received her BS in Physical Therapy from SUNY Buffalo, her MSM from Rollins College, and her DBAS at Nova Southeastern.

• ContentsContributorsPrefaceAcknowledgementsSECTION 1 How to Write Patient Care Notes1. Introduction, Background, Purpose, and General Rules for Health Information Management2. Record Organization and General Principles3. Application of Models for Organization and Guidelines for Content4. The Electronic Medical Record5. Content Standardization and Component Requirements6. Documentation for Pediatrics7. Documentation for Home Health8. Documentation for Certified Nursing HomesSECTION 2 How to Document Clinical Decision-Making9. Evidence-Based Practice10. Clinical Decision-Making11. Legal Issues in the Medical Record12. Utilization Review and Utilization ManagementSECTION 3 Payment and Coding13. Coding14. Documentation Content Principles15. Alternative Payment ModelsSECTION 4 Steps and Framework for Coding and Documentation16. Documentation Writing Examples and WorksheetsAppendix A AbbreviationsAppendix B OASIS DAppendix C CMS Form 1500 with InstructionsAppendix D ICD-10 GuidelinesAppendix E APTA Guidelines for Physical Therapy DocumentationAppendix F APTA Documentation Review ChecklistIndex