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Documentation Manual for Writing SOAP Notes in Occupational Therapy

Documentation Manual for Writing SOAP Notes in Occupational Therapy - 2nd edition

ISBN13: 978-1556427190

Cover of Documentation Manual for Writing SOAP Notes in Occupational Therapy 2ND 06 (ISBN 978-1556427190)
ISBN13: 978-1556427190
ISBN10: 1556427190
Cover type:
Edition/Copyright: 2ND 06
Publisher: Slack Inc.
Published: 2006
International: No

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Documentation Manual for Writing SOAP Notes in Occupational Therapy - 2ND 06 edition

ISBN13: 978-1556427190

Sherry Borcherding

ISBN13: 978-1556427190
ISBN10: 1556427190
Cover type:
Edition/Copyright: 2ND 06
Publisher: Slack Inc.

Published: 2006
International: No
Summary

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.

This workbook successfully uses a "how to" approach to explain the critical skill of documentation. 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.

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.

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.

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.
  • 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.

Table of Contents

Chapter 1. Documenting the Occupational Therapy Process
Chapter 2. The Health Record
Chapter 3. Writing Functional Problem Statements
Chapter 4. Writing Functional and Measurable Goals and Objectives
Chapter 5. Writing the "S"---Subjective
Chapter 6. Writing the "O"--Objective
Chapter 7. Writing the "A"--Assessment
Chapter 8. Writing the "P"--Plan
Chapter 9. Intervention Planning
Chapter 10. Documenting Different Stages of Treatment
Chapter 11. Documentation in Different Practice Settings
Chapter 12. Making Good Notes Even Better
Chapter 13. Examples of Different Kinds of Notes

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