Documentation Manual for Writing SOAP Notes in Occupational Therapy

ISBN-10: 1556427190
ISBN-13: 9781556427190
Edition: 2nd 2005
List price: $49.95
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Description: One of the most critical skills today’s occupational therapists will need to learn and master is documentation. The most successful workbook on the market to educate students and keep professionals sharp is Documentation Manual for Writing SOAP  More...

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Book details

List price: $49.95
Edition: 2nd
Copyright year: 2005
Publisher: SLACK, Incorporated
Publication date: 9/2/2005
Binding: Paperback
Pages: 256
Size: 8.50" wide x 11.00" long x 0.75" tall
Weight: 1.386
Language: English

One of the most critical skills today’s occupational therapists will need to learn and master is documentation. The most successful workbook on the market to educate students and keep professionals sharp is Documentation Manual for Writing SOAP Notes in Occupational Therapy—now available in an improved and revised second edition . nbsp; This workbook successfully uses a “how to” approach to explain the critical skill of documentation.nbsp; By concentrating on the instruction of one essential skill and not diverging into other related areas, this new edition allows occupational therapists to focus completely on writing SOAP notes. nbsp; Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition is designed to break down the task of SOAP documentation into manageable units of skill sets. Sherry Borcherding has identified the concepts that are the most difficult to grasp and has incorporated new worksheets to help better understand these important terms. nbsp; The new edition of this indispensable workbook provides a better representation of the major practice settings in which occupational therapists are employed, including mental health and pediatric settings. Complementary therapies have also been included with examples of documentation for two common techniques, CranioSacral Therapy and Tai Chi. nbsp; New worksheets, revised chapters, and clinical examples ensure that Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition will be the only resource needed by occupational therapy students and professionals. Features of the Second Edition include: Documentation skills based on the concepts found in the Occupational Therapy Practice Framework. An explanation of The AOTA’s Guidelines for Documentation of Occupational Therapy Practice, including examples. A brief discussion of HIPAA, billing codes, and their importance in reimbursement. Detachable worksheets that walk students through the skills needed for successful documentation in the client’s health record. A detachable checklist to be used as a quick reference when evaluating your SOAP Note to ensure that all of the essential elements are included. Clinical examples that show a variety of successful wordings for each concept. Reorganized chapters that offer a user-friendly format and logical presentation of material.

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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