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In 2009, the 4th edition of this book was published. At that time, the Guide to Physical Therapist Practice was in paper form and had been in existence for some time. I asked three people to contribute chapters on the Medical Record and the International Classification of Functioning, Disability, and Health (ICF) System. Since that time, a new online-only 3rd edition of the Guide to Physical Therapist Practice has been published, G-codes have come into use, one of my contributors has retired, and another has left the University to work for a health system. The medical record is now called the health record and is most often in electronic format. Students now are taught the terms of Impairments of Structure and Function, Activity Limitations, and Participation Restrictions—all ICF terms.

As I looked at working on the current 5th edition of this book, I realized the need for a colleague who is practicing to update the cases in the worksheets to fit modern, evidence-based practice. Sarah Schlomer, PT, DPT, took on the challenge, contributed to every chapter, and wrote the worksheets. She also took on the challenge of carrying cases from one worksheet to another so that students can see the progression of patients through the process of examination, evaluation, and treatment.

We frequently discussed the need for a workbook in which students would practice writing notes in the world of computerized documentation. Over and over again, we came back to the fact that students need to know and practice the components of writing notes to understand the process of clinical decision-making and the process of documenting in an electronic health record.

As in the past, this textbook assumes that the user has access to the Guide to Physical Therapist Practice. The intended primary audience of this book is a group of very new students in the professions of physical and occupational therapy. It is our intent that this book model how to put into practice the described processes in the Guide to Physical Therapist Practice, 3rd edition.

Every edition of this book has required a number of people to get the work done. The editors at F. A. Davis continued to show patience and support as we slowly worked through collaborating on this revision of the book. My husband, Gerry, is my forever partner and support through life, always encouraging me to persist in working through the revision process, always giving up things he would like to be doing to support me as I go through the process of writing. Without Gerry, this book would not exist and would never be revised. My daughters, Kristen and Kathryn, grew up watching me write and as adults continue to be supportive. As adults, they still help cover when I am too busy to do other things that need to be done in our lives because I am writing.

My final thanks go to my colleagues at Saint Louis University, particularly those who have contributed to this book. With sadness I remember Theresa Bernsen, a colleague whom we lost suddenly to heart disease in 2010. We retained quite a bit of her writing in the ICF chapter. My colleague in the Health Sciences and Informatics Department, Dr. Jody Smith, revised the three chapters about the health record and reimbursement, areas in which she is a true expert. Sarah Schlomer revised Theresa's material on ICF and wrote Chapter 22, The Medicare Therapy Cap, KX Modifiers, and Functional Limitations Reporting (G-Codes), in addition to the worksheets. Jill FitzGerald, PT, DPT, GCS, wrote the teaching materials supplied in DavisPlus, including optional additional practice worksheets, a sample semester-long course schedule, chapter quizzes, and midterm and final exams.

Every time I have revised this book, I have thought about the people learning from this book. It is written to help students learn about documentation and to give them practice with documentation while modeling the clinical decision-making that occurs during patient care. Physical therapists, occupational therapists, and athletic trainers do important work. They measure, evaluate, analyze, plan, and teach. Documentation of all of these functions is important. This book is only a small step in all of the things that must be learned to become a good therapist or athletic trainer. It is my hope that it significantly contributes to the clinical practice success of all of the future health professionals who learn from it.


Most people think that writing is a solitary endeavour. That an author spends the day locked in a room for long hours attempting to imagine something to place on those blank pages. However, an author does not do it alone. The truth is, I am here because of the people in my life.

Much gratitude is owed to the many people involved with the making of the 5th edition of this text. First, I owe a great deal of thanks to Ginge Kettenbach, PhD, PT, for the inception of the idea for a textbook with worksheets so that students could learn in a practical manner the value and skill of note writing, a daily staple of the therapy profession. As we all know, if you do not document it, it never happened. Just as the students who fully utilize this text will learn the new skill of note writing, I, too, began the journey of learning about writing a textbook when I accepted the offer to assist Dr. Kettenbach with the 5th edition of this book. I am grateful to have been given this opportunity.

Second, I did not know what I was getting into when I agreed to assist with this edition, but thanks to all those involved in the editorial process from start to finish, I have a gained better understanding of the overall process and the roles of each person involved. Melissa Duffield, the Acquisitions Editor, was instrumental in laying out the publisher's vision for this new edition of the text and the ancillaries involved with it in our ever-changing educational world. The Developmental Editor, Molly Ward, was kind enough to answer my many questions and provide her insights with regard to each step of the process.

Next, I need to thank those closest to me as they have each, in their own unique ways, encouraged me to keep ploughing through to the finish line of this text despite the many daily demands and long hours with working in the clinic. To my fiance, Luke, my mother, Helen, and my sister, Megan, your love and support from near and far away have been invaluable.

I would also like to thank the late Theresa Bernsen. I first met her as a student in the PT program at Saint Louis University, and the knowledge that I gained through her classes, as well as her mentorship after graduation, impacts my daily life as a physical therapist. Aside from being a true WHO ICF expert, she was simply brilliant. The knowledge that she bestowed on each person she touched was empowering. While she is missed, her expertise carries on here in the ICF chapter.

Finally, I would be amiss if it I did not thank the numerous clients I have been privileged to work with over the years in a vast number of settings. Your perseverance in some of the most difficult situations imaginable is inspiring. You continually motivate me to give my all on a daily basis, and I have learned much about myself as a therapist and a person through my interactions with each of you.


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