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Documentation for Physical Therapist Practice: A Clinical Decision Making Approach Includes Navigate 2 Advantage Access

Author(s): Jacqueline A. Osborne, PT, DPT, GCS, CEEAA, Geriatric Residency Coordinator, Brooks Rehabilitation, Jacksonville, Florida
  • ISBN-13: 9781284034226
  • Navigate 2 Advantage Access     262 pages      © 2016
Price: $67.95 US List
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Each new print copy includes Navigate 2 Advantage Access that unlocks a comprehensive and interactive eBook, student practice activities and assessments, a full suite of instructor resources, and learning analytics reporting tools.

Documentation for Physical Therapist Practice: A Clinical Decision Making Approach provides the framework for successful documentation. It is synchronous with Medicare standards as well as the American Physical Therapy Association’s recommendations for defensible documentation. It identifies documentation basics which can be readily applied to a broad spectrum of documentation formats including paper-based and electronic systems. This key resource utilizes a practical clinical decision making approach and applies this framework to all aspects of documentation. This text emphasizes how the common and standard language of the Guide to Physical Therapist Practice and the International Classification of Functioning, Disability, and Health (ICF) model can be integrated with a physical therapist’s clinical reasoning process and a physical therapist assistant’s skill set to produce successful documentation.

  • Includes content on documentation formations: Initial Evaluations, Re-examination Notes, Daily Notes, Conclusion of the Episode of Care Summaries, Home Exercise Programs
  • Reviews all the important issues related to style, types of documentation, and utilization of documentation
  • Covers documentation relevant in different settings (inpatient, home health, skilled nursing facility, outpatient)  
  • Helps students learn how to report findings and demonstrate an appropriate interpretation of results
  • Includes up-to-date information in line with APTA Guidelines for Defensible Documentation, World Health Organization, International Classification of Functioning Disability and Health, and Medicare
  • Reviews electronic documentation, ICD-9, ICD-10, and CPT codes
  • Includes important chapters on Interprofessional Communication, Legal Aspects, Principles of Measurement

Instructor Resources: Sample Answers to Case Study and Discussion Questions, Key Image Review, Slides in PowerPoint format, Test Bank

With Navigate 2, technology and content combine to expand the reach of your classroom. Whether you teach an online, hybrid, or traditional classroom-based course, Navigate 2 delivers unbeatable value. Experience Navigate 2 today at

Features & Benefits

Pedagogy: Chapter Objectives, Case Studies, End-of-chapter Review Questions.
Instructor Resources: Answers to Case Study Questions, Answers to Discussion Questions, Key Image Review, Slides in PowerPoint format, Test Bank

Applicable Courses

Foundations in Physical Therapy
Physical Therapy Interventions
Interprofessional Communication
Caring for the Community
SOAP Notes

Chapter  1  Documentation: An Essential Element of Physical Therapy Practice
Chapter  2  Utilizing the International Classification of Functioning, Disability and Health (ICF) Model in Physical Therapy Documentation
Chapter  3  Documenting the Initial Examination
Chapter  4  Writing Daily Notes
Chapter  5  Documenting the Home Exercise Program
Chapter  6  Documenting Progress
Chapter  7  Conclusion of the Episode of Care
Chapter  8  Principles of Measurement in Documentation
Chapter  9  Interprofessional Communication
Chapter  10  Electronic Health Records: The Medium for Documentation
Chapter  11  The Impact of Health Care Reform on Physical Therapy Documentation
Chapter  12  Legal Considerations in Physical Therapy Documentation

Jacqueline A. Osborne, PT, DPT, GCS, CEEAA-Geriatric Residency Coordinator, Brooks Rehabilitation, Jacksonville, Florida

Jacqueline A. Osborne, PT, DPT, GCS, CEEAA is the Director of the Geriatric Residency Program, at Brooks Rehabilitation, a non-profit rehabilitation system in Jacksonville, Florida.  In addition to this role, she maintains a clinical practice at Brooks Rehabilitation and serves the American Physical Therapy Association (APTA), the American Board of Physical Therapy Specialties (ABPTS), the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE), the Florida Physical Therapy Association (FPTA), and the Florida Injury Prevention Advisory Council (FIPAC) as a member of a variety of workgroups and taskforces.

Dr. Osborne received a Bachelor of Science degree in Business Administration with a concentration in Operations Management from the University of Delaware in 2000 and a Doctor of Physical Therapy Degree from Beaver College (now Arcadia University) in Glenside, Pennsylvania in 2003.  She obtained Board Certification in the area of Geriatric Physical Therapy from the American Board of Physical Therapy Specialties in 2007.  She also obtained the credential of Certified Exercise Expert for Aging Adults (CEEAA) from the Section on Geriatrics (now the Academy of Geriatric Physical Therapy) of the American Physical Therapy Association in 2012.

Dr. Osborne has a passion of for the care of older adults. She is an advocate for this group in many ways.  One way that she works on behalf of older adults on routine basis, however, is through her clinical documentation.  There is little more valuable than obtaining needed resources known to benefit patients or clients because of successful documentation!  With this text, she hopes to share an approach to documentation rooted in clinical decision-making that will continuously serve as an adjunct to clinicians to advocate for patients and clients in clinical practice.


  • "While there are several documentation texts currently available, [Documentation for Physical Therapy] seems to take all of the best aspects of other texts in mind and combines them in one. I do think there is a place for this text for both clinical and academic use. The information appears very up to date (Guide, ICF, evidence based practice) and is supportive of professional and legal standards."
    ~ Mary Dockter, PT, PhD, Program Director, University of Mary

  • "Several strengths-1) organization of the template for a common written language with emphasis on APTA Patient/Client Management Model, 2) vigilance with electronic documentation since many software programs are lacking sufficient options for complete client examinations with increased potential for errors using electronic documentation, and 3) an interactive workbook and PowerPoint slides for the instructor are excellent features. This text addresses all the aspects of good documentation for a doctoring profession."
    ~ Patricia Hodson, PT, DPT, Clinical Professor, East Carolina University

  • "Strengths are that the text tackles making documentation consistent with Medicare guidelines as well as APTA defensible documentation. Author also acknowledges that there are many different types of documentation including paper as well as the electronic medical record."
    ~ Christine Kasinskas, DPT, Assistant Professor, Quinnipiac University

  • [Documentation for Physical Therapist Practice] is very student-friendly; it is noted that this well-written text represents the current and future models of documentation for the practicing physical therapist.”

                ~ Valerie Dong Wilson, PhD, Program Director, Dominican College

  • “The author is certainly visionary and has an excellent grasp of the trends and evolutions in the PT profession as well as overall healthcare reform.”

                ~ Christopher Wilson, PT, DPT, CGS, Clinical Assistant Professor, Oakland University


  • Chapter 1
    Chapter 1: Documentation: An Essential Element of Physical Therapist Practice
  • Chapter 9
    Chapter 9: Interprofessional Communication
  • Front Matter
    Front Matter

The following instructor resources are available to qualified instructors for download

ISBN-13: 9781284034226

Case Studies
Discussion Questions
Image Bank
Lecture Outline
Slides in PowerPoint Format
Test Bank

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