Defensible Documentation: A Framework for Physical Therapy Documentation
This purpose of this session is to help students and practicing therapists develop an efficient and effective documentation strategy appropriate for use across a wide range of practice settings and patient populations. This approach is grounded in the ICF framework and will facilitate a clinical decision making approach to optimize patient outcomes. The framework further incorporates both the APTA’s Guidelines for Physical Therapy Documentation and the Guide to Physical Therapist Practice, and is consistent with Medicare and third-payer guidelines for functional outcomes assessment. The talk will cover documentation of the initial evaluation, daily notes and progress reports, and will specifically address movement system diagnoses, goal-setting and functional outcomes assessments. We will provide actual clinical examples from a range of patient populations and clinical practice settings. Participants will have the opportunity to practice documentation skills and ask individual questions pertaining to their current practice.
Meet our Speakers
Lori Quinn, PT, EdD is associate professor in the Department of Biobehavioral Sciences, Teachers College, Columbia University, in New York, New York. Her research has focused on developing evidence and guidelines for physical therapy interventions in neurodegenerative diseases, and in particular, for people with Huntington’s disease and Parkinson’s disease. She has developed treatment-based classifications for individuals with Huntington’s disease, and has coauthored several papers related to developing classifications to guide interventions. In addition to her work in neurodegenerative diseases, she is coauthor of Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, currently in its third edition. The textbook places a strong emphasis on diagnosis by physical therapists, and using documentation to guide effective clinical management.
Julie Fineman, PT, EdM is the Director of Clinical Education and Clinical Assistant Professor for Marist College’s Doctor of Physical Therapy Program. Julie is a physical therapist with over 30 years experience in a variety of practice settings including in-patient, out-patient and home care. Prior to joining Marist, Julie was an Assistant Professor in the Physical Therapy Programs at Stony Brook University, New York Medical College and Dominican College. She received her BS in Physical Therapy from University of Delaware and her MA and EdM degrees in Motor Learning & Control from Teacher’s College, Columbia University. Julie is a chapter author of the textbook: Documentation for rehabilitation: a guide to clinical decision making in physical therapy. She is currently pursuing her EdD degree with research investigating skill acquisition and dual task paradigms in individuals with Parkinson’s disease.
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- Understand the theoretical framework supporting physical therapy documentation based on the ICF model and the Guide to Physical Therapist Practice.
- Align the components of the initial evaluation with the processes of the Guide to Physical Therapists Practice - Patient/Client Management Model.
- Recognize the necessity of specificity in all components of documentation.
- Be able to document patient-centered, specific and measurable goals that address activity-level limitations.
- Be able to document a complete assessment that includes a movement system diagnosis.
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