Documentation Manual for Writing SOAP Notes in Occupational Therapy

Name: Documentation Manual for Writing SOAP Notes in Occupational Therapy
Price: 11.37 USD
Availability: InStock
ISBN: 9781556424410

ISBN-10: 1556424418

ISBN-13: 9781556424410

Edition: N/A

Authors: Sherry Borcherding

List price: $29.95

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Description:

This exciting new manual presents a systematic approach to writing one form of documentation, the SOAP note. The purpose of this text is to teach readers to write SOAP notes that will be reimbursable under Medicare, Part B, and managed care. With the current changes in healthcare, documentation of patient care is essential to meet standards for reimbursement of services. SOAP notes prepare students for real-world clinical practice, effectively teaching the mechanics of writing problem statements and goals, and addressing documentation in different stages of treatment and practice settings. The author walks the reader through each step of the documentation process, effectively teaching the…

Book details

List price: $29.95
Publisher: SLACK, Incorporated
Publication date: 3/14/2000
Binding: Paperback
Pages: 256
Size: 8.75" wide x 11.25" long x 0.75" tall
Weight: 1.386
Language: English



Dedication


Acknowledgments


About the Author



Documenting the Treatment Process in Occupational Therapy



The Medical Record



Using Abbreviations



Additional Practice



Writing Functional Problem Statements



Writing Functional Problem Statements



Writing Functional and Measurable Goals and Objectives



Choosing Goals for Medical Necessity



Evaluating Goal Statements



Writing Realistic, Functional Measurable Goals



Writing the "S"--Subjective



Choosing a Subjective Statement



Writing the "O"--Objective



Being More Concise



Being Specific About Assist Levels



Deemphasizing the Treatment Media



Writing the "A"--Assessment



Justifying Skilled Occupational Therapy



Writing the "P"--Plan



A Treatment Session Devoted to ADL Activities



Treatment Planning



Treatment Plan for Donald G.



Treatment Plan for Ginny H.



Documenting Different Stages of Treatment



Initial Evaluation Report



Contact, Visit, or Treatment Notes



Progress Notes



Reevaluation Report



Discharge Summary #1 (SOAP Format)



Discharge Summary #2 (Facility Form)



Documentation in Different Practice Settings



Making Good Notes Even Better



Problem Statements



Goals



SOAPing Your Note



Subjective



Objective



Assessment



Plan



Assessment and Plan



A Note That Needs Some Therapy



The "Almost" Note



Examples of Different Kinds of Notes


Bibliography



Suggestions for Completing the Worksheets


Note to the Reader


Index