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OTA's Guide to Writing SOAP Notes

OTA's Guide to Writing SOAP Notes - 02 edition

ISBN13: 978-1556425516

Cover of OTA
ISBN13: 978-1556425516
ISBN10: 1556425511
Cover type:
Edition/Copyright: 02
Publisher: Slack Inc.
Published: 2002
International: No

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OTA's Guide to Writing SOAP Notes - 02 edition

ISBN13: 978-1556425516

Sherry Borcherding and Carol Kappel

ISBN13: 978-1556425516
ISBN10: 1556425511
Cover type:
Edition/Copyright: 02
Publisher: Slack Inc.

Published: 2002
International: No
Summary

Written by and specifically for Occupational Therapy Assistants, The OTA's Guide to Writing SOAP Notes is an instruction manual for teaching a specific skill: documentation as required for reimbursement in occupational therapy. With the current changes in healthcare, documentation of patient care is essential to meet standards for reimbursement of services. The purpose of this new text is to teach the Occupational Therapy Assistant to write SOAP notes that will be reimbursable under Medicare Part B and managed care.Documentation is learned in the same way that any other skill is learned-instruction and practice. The OTA's Guide to Writing SOAP Notes is the only text that provides instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional new text offers both the necessary instruction and multiple opportunities to practice, as skills are built on each other in a logical manner. Templates are provided for beginning students to use in formatting the SOAP note, and the task of documentation is broken down into small units to make learning easier.A detachable summary sheet is included that can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. "Answers" are provided for all worksheets so that the text can be used for independent study if desired.

Table of Contents

Chapter One. Documenting the Treatment Process in Occupational Therapy

Chapter Two. The Medical Record

Worksheet 2-1. Using Abbreviations
Worksheet 2-2. Additional Practice

Chapter Three. Writing the Subjective

Worksheet 3-1. Writing Concise, Coherent Statements
Worksheet 3-2. Choosing a Subjective Statement

Chapter Four. Writing the Objective

Worksheet 4-1. Choosing Categories
Worksheet 4-2. Being Specific About Assist Levels
Worksheet 4-3. De-Emphasizing the Treatment Media
Worksheet 4-4. Being Concise

Chapter Five. Writing the Assessment

Worksheet 5-1. Justifying Continued Treatment
Worksheet 5-2. Assessing the Categories Note
Worksheet 5-3. Assessing Problems Not Within Functional Limits
Worksheet 5-4. Assessing a Note

Chapter Six. Writing the Plan

Worksheet 6-1. Final SOAP Note for a Treatment Session Written in Categories
Worksheet 6-2. Completing the Plan for the Postural Instability Note
Worksheet 6-3. The Exercise Note
Worksheet 6-4. A Treatment Session Devoted to ADL Activities

Chapter Seven. Goals and Interventions

Worksheet 7-1. Evaluating Goal Statements
Worksheet 7-2. Writing Realistic, Functional, and Measurable Goals
Worksheet 7-3. Mrs. Murphy's Wheelchair Mobility
Worksheet 7-4. Interrupted Interventions

Chapter Eight. Documenting Different Stages of Treatment

Worksheet 8-1. Initial Evaluation Report
Worksheet 8-2. Progress Notes
Worksheet 8-3. Contact, Visit, or Treatment Notes
Worksheet 8-4. Reevaluation Report
Worksheet 8-5. Discharge Summary #1 (SOAP Format)
Worksheet 8-6. Discharge Summary #2 (Facility Form)

Chapter Nine. Documentation in Different Practice Settings

Chapter Ten. Making Good Notes Even Better

Worksheet 10-1. Soaping Your Note
Worksheet 10-2. Subjective
Worksheet 10-3. Writing Good Opening Sentences
Worksheet 10-4. Writing a Complete and Concise Objective
Worksheet 10-5. Differentiating Between Observations and Assessments
Worksheet 10-6. Assessment and Plan
Worksheet 10-7. The Almost Note
Worksheet 10-8. Writing Functional and Measurable Goals
Worksheet 10-9. Creative Treatment Interventions

Chapter Eleven. Examples of Different Kinds of Notes


Bibliography
Appendix: Suggestions for Completing the Worksheets
Index

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