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Documentation Manual for Writing SOAP Notes in Occupational Therapy

ISBN-10: 1556424418
ISBN-13: 9781556424410
Edition: N/A
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  More...

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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

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 mechanics of writing problem statements and goals and addressing documentation in different stages of treatment and practice settings. Written in a manual format, this book provides the reader with: A step-by-step “how to” approach to documenting the occupational therapy process. Skills broken down into small steps and taught individually. A format or “template” for writing problems, goals, and each section of the SOAP note. A list of common abbreviations and symbols used in documentation. Examples of notes from many practice areas and stages of the documentation process. Worksheets that provide quick checklist and summary that can be carried into clinical situations to remind the reader of the essential requirements for SOAP notes. Documentation Manual for Writing SOAP Notes in Occupational Therapy is the only manual that teaches a skill focusing on the specific requirements of OT application, and then provides the opportunity for practice with exercises and examples presented throughout the book.

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

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