Documentation Manual for Writing SOAP Notes in Occupational Therapy / Edition 2

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Overview

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.

The book contains black-and-white illustrations.

This exciting new manual presents a systematic approach to writing S.O.A.P. note documentation. The purpose of this text is to teach readers to write S.O.A.P. notes that will be reimburseable 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. S.O.A.P notes prepare students for real-world clinical practice, and effectively teach the mechanics of writing problem statements and goals, as well as addressing documentation in different stages of treatment and practice settings.

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Editorial Reviews

Booknews
Teaches a skill focusing on specific requirements of occupational therapy documentation and provides an opportunity for practice with exercises and examples. Walks readers through each step in the process of writing SOAP notes that will be reimbursable under Medicare Part B and managed care, with step-by-step instructions, a format for writing each section of the SOAP note, and examples from many practice areas. Includes worksheets, detachable checklists for use in clinical situations, and a list of common abbreviations and symbols. The author is affiliated with the University of Missouri. Annotation c. Book News, Inc., Portland, OR (booknews.com)
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Product Details

  • ISBN-13: 9781556427190
  • Publisher: SLACK, Incorporated
  • Publication date: 9/1/2005
  • Edition description: Second
  • Edition number: 2
  • Pages: 256
  • Product dimensions: 8.50 (w) x 11.00 (h) x 0.55 (d)

Meet the Author

Sherry Borcherding, MA, OTR/L currently serves as a faculty member at University of Missouri–Columbia, a Carnegie Research Extensive University, where she has taught since 1992. She teaches disability awareness, complementary therapy, and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. She has also taught clinical ethics, frames of reference, psychopathology, loss and disability, long-term care, and wellness. Two of her courses are designated as campus writing courses and one is credentialed for computer and information proficiency. Sherry is frequently invited to present on collaborative learning, peer review, and educational technology. Sherry graduated with honors from Texas Woman's University with a BS in occupational therapy and went on to complete her master's in special education with special faculty commendation at George Peabody College in Nashville, TN. Following her staff positions in rehabilitation, home health, and pediatrics, she assumed a number of management roles, including Chief Occupational Therapist at East Texas Treatment Center, Director of Occupational Therapy at Mid-Missouri Mental Health Center, and Director of Rehabilitation Services at Transitional Housing Agency. She has also planned, designed, and directed occupational therapy programs at Capital Regional Medical Center in Jefferson City, MO and at Charter Behavioral Health Center in Columbia, MO. Besides teaching, Sherry consults on quality assurance issues for local behavioral health centers and has a private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy at the techniques level through Upledger Institute and is attuned as a Reiki master. For leisure, Sherry enjoys folk dance, music, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past two years. Marie J. Morreale, OTR/L, CHT has been teaching in the Occupational Therapy Assistant Program at Rockland Community College since 1998. She is part of the adjunct faculty and currently teaches Professional Issues and Documentation, OT Skills, Geriatric Principles, and Advanced OT Skills. Besides making significant contributions to curriculum development, Marie has served as interim program coordinator and has also taught several other courses in the OTA program, including OT Therapeutic Activities and Advanced Therapeutic Activities. Since graduating Summa Cum Laude from Quinnipiac College (now Quinnipiac University), Marie has worked in a variety of OT practice settings, including inpatient and outpatient rehabilitation, long-term care, adult day care, home health, cognitive rehabilitation, and hand therapy. She also served for several years on a home health Professional Advisory Committee (consulting on quality assurance issues), and has been a Certified Hand Therapist since 1993. In addition, Marie is the author of several online continuing education courses and was selected for Who’s Who Among America’s Teachers in 2003-2004. When not teaching, Marie is an active member of her church community where she voluntarily chairs various fundraising events and community activities. In addition, Marie is an avid reader and she also enjoys all kinds of domestic and international travel.

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Table of Contents

Dedication v
Acknowledgments ix
About the Author xi
Chapter 1. Documenting the Treatment Process in Occupational Therapy 1
Chapter 2. The Medical Record 7
Worksheet 2-1. Using Abbreviations 15
Worksheet 2-2. Additional Practice 17
Chapter 3. Writing Functional Problem Statements 19
Worksheet 3-1. Writing Functional Problem Statements 23
Chapter 4. Writing Functional and Measurable Goals and Objectives 25
Worksheet 4-1. Choosing Goals for Medical Necessity 29
Worksheet 4-2. Evaluating Goal Statements 33
Worksheet 4-3. Writing Realistic, Functional Measurable Goals 35
Chapter 5. Writing the "S"--Subjective 39
Worksheet 5-1. Choosing a Subjective Statement 43
Chapter 6. Writing the "O"--Objective 45
Worksheet 6-1. Being More Concise 53
Worksheet 6-2. Being Specific About Assist Levels 55
Worksheet 6-3. Deemphasizing the Treatment Media 59
Chapter 7. Writing the "A"--Assessment 61
Worksheet 7-1. Justifying Skilled Occupational Therapy 65
Chapter 8. Writing the "P"--Plan 71
Worksheet 8-1. A Treatment Session Devoted to ADL Activities 81
Chapter 9. Treatment Planning 83
Worksheet 9-1. Treatment Plan for Donald G. 89
Worksheet 9-2. Treatment Plan for Ginny H. 91
Chapter 10. Documenting Different Stages of Treatment 99
Worksheet 10-1. Initial Evaluation Report 107
Worksheet 10-2. Contact, Visit, or Treatment Notes 111
Worksheet 10-3. Progress Notes 115
Worksheet 10-4. Reevaluation Report 119
Worksheet 10-5. Discharge Summary #1 (SOAP Format) 123
Worksheet 10-6. Discharge Summary #2 (Facility Form) 127
Chapter 11. Documentation in Different Practice Settings 129
Chapter 12. Making Good Notes Even Better 149
Worksheet 12-1. Problem Statements 151
Worksheet 12-2. Goals 153
Worksheet 12-3. SOAPing Your Note 155
Worksheet 12-4. Subjective 157
Worksheet 12-5. Objective 161
Worksheet 12-6. Assessment 163
Worksheet 12-7. Plan 165
Worksheet 12-8. Assessment and Plan 167
Worksheet 12-9. A Note That Needs Some Therapy 169
Worksheet 12-10. The "Almost" Note 171
Chapter 13. Examples of Different Kinds of Notes 179
Bibliography 199
Appendix Suggestions for Completing the Worksheets 201
Note to the Reader 229
Index 231
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