I. Why Is Documentation Important?
1. Introduction to Documentation
2. The World Health Organization and the International Classification of Functioning, Disability and Health
3. Demystifying the ICD-10 Coding System
4. Reimbursement Issues Related to Documentation
5. Documentation Content and Organization
6.Physical Therapy Patient Management and Documentation Responsibilities
II. How Do SOAP Notes Ensure Good Patient Care?
7. How Does Documentation Relate to Patient Issues?
8. Your Documentation Related to Legal and Ethical Issues
III. Steps to Documentation
9.Introduction to the SOAP Note
10.What Are Subjective Data and Why Are They Important?
11.What Are Objective Data and Why Are They Important?
12. What Are Assessment Data and Why Are They Important?
13. What Is the Plan and Why Is It Important?
IV. Testing What You Know
14.Putting the Pieces Together
15.Do You Know Enough?
B. Defensible Documentation Elements and Documentation Review Sample Checklist
C. SOAP Note Rubric
D. Documenting Interventions