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

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

by Sherry Borcherding
     
 

ISBN-10: 1556427190

ISBN-13: 9781556427190

Pub. Date: 09/01/2005

Publisher: SLACK, Incorporated

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

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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.

Product Details

ISBN-13:
9781556427190
Publisher:
SLACK, Incorporated
Publication date:
09/01/2005
Edition description:
Second
Pages:
256
Product dimensions:
8.50(w) x 11.00(h) x 0.55(d)

Table of Contents

Dedicationv
Acknowledgmentsix
About the Authorxi
Chapter 1.Documenting the Treatment Process in Occupational Therapy1
Chapter 2.The Medical Record7
Worksheet 2-1.Using Abbreviations15
Worksheet 2-2.Additional Practice17
Chapter 3.Writing Functional Problem Statements19
Worksheet 3-1.Writing Functional Problem Statements23
Chapter 4.Writing Functional and Measurable Goals and Objectives25
Worksheet 4-1.Choosing Goals for Medical Necessity29
Worksheet 4-2.Evaluating Goal Statements33
Worksheet 4-3.Writing Realistic, Functional Measurable Goals35
Chapter 5.Writing the "S"--Subjective39
Worksheet 5-1.Choosing a Subjective Statement43
Chapter 6.Writing the "O"--Objective45
Worksheet 6-1.Being More Concise53
Worksheet 6-2.Being Specific About Assist Levels55
Worksheet 6-3.Deemphasizing the Treatment Media59
Chapter 7.Writing the "A"--Assessment61
Worksheet 7-1.Justifying Skilled Occupational Therapy65
Chapter 8.Writing the "P"--Plan71
Worksheet 8-1.A Treatment Session Devoted to ADL Activities81
Chapter 9.Treatment Planning83
Worksheet 9-1.Treatment Plan for Donald G.89
Worksheet 9-2.Treatment Plan for Ginny H.91
Chapter 10.Documenting Different Stages of Treatment99
Worksheet 10-1.Initial Evaluation Report107
Worksheet 10-2.Contact, Visit, or Treatment Notes111
Worksheet 10-3.Progress Notes115
Worksheet 10-4.Reevaluation Report119
Worksheet 10-5.Discharge Summary #1 (SOAP Format)123
Worksheet 10-6.Discharge Summary #2 (Facility Form)127
Chapter 11.Documentation in Different Practice Settings129
Chapter 12.Making Good Notes Even Better149
Worksheet 12-1.Problem Statements151
Worksheet 12-2.Goals153
Worksheet 12-3.SOAPing Your Note155
Worksheet 12-4.Subjective157
Worksheet 12-5.Objective161
Worksheet 12-6.Assessment163
Worksheet 12-7.Plan165
Worksheet 12-8.Assessment and Plan167
Worksheet 12-9.A Note That Needs Some Therapy169
Worksheet 12-10.The "Almost" Note171
Chapter 13.Examples of Different Kinds of Notes179
Bibliography199
AppendixSuggestions for Completing the Worksheets201
Note to the Reader229
Index231

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