The OTA's Guide to Writing SOAP Notes / Edition 2

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Written specifically for occupational therapy assistants, The OTA’s Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. This valuable text contains the step-by-step instruction needed to learn the documentation required for reimbursement in occupational therapy.

With the current changes in healthcare, proper documentation of client care is essential to meeting legal and ethical standards for reimbursement of services. Written in an easy-to-read format, this new edition by Sherry Borcherding and Marie J. Morreale will continue to aid occupational therapy assistants in learning to write SOAP notes that will be reimbursable under Medicare Part B and managed care for different areas of clinical practice.

New Features in the Second Edition:
• Incorporated throughout the text is the Occupational Therapy Practice Framework, along with updated AOTA documents
• More examples of pediatrics, hand therapy, and mental health
• Updated and additional worksheets
• Review of grammar/documentation mistakes
• Worksheets for deciphering physician orders, as well as expanded worksheets for medical abbreviations
• Updated information on billing codes, HIPAA, management of health information, medical records, and electronic documentation
• Expanded information on the OT process for the OTA to fully understand documentation and the OTA’s role in all stages of treatment, including referral, evaluation, intervention plan, and discharge
• Documentation of physical agent modalities

With reorganized and shorter chapters, The OTA’s Guide to Writing SOAP Notes, Second Edition is the essential text to providing instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional edition 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 SOAP notes, 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.

Updated information, expanded discussions, and reorganized learning tools make The OTA’s Guide to Writing SOAP Notes, Second Edition a must-have for all occupational therapy assistant students! This text is the essential resource needed to master professional documentation skills in today’s healthcare environment.

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Editorial Reviews

From the Publisher

“This textbook accomplishes what it sets out to do – provide basic concepts of documentation for the OTA student. It…provides a well-rounded overview of documentation in various treatment settings at the assistant level…This textbook allows the instructor to systematically work through the various elements of documentation with the students…I like the easy-going way the textbook is written. Students are not intimidated when they read it – it’s definitely on their level and is very encouraging to them as they work through it.”

—Lindsay Lawrence, Jefferson Community and Technical College, KY

From The Critics
Written by and for occupational therapy assistants, this guide details documentation of patient care as required for reimbursement under Medicare Part B and managed care. Numerous worksheets and examples are provided, as are detachable summaries which can be carried to clinical sites as reminders. Annotation c. Book News, Inc., Portland, OR
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Product Details

  • ISBN-13: 9781556427794
  • Publisher: SLACK, Incorporated
  • Publication date: 12/1/2006
  • Edition description: Second
  • Edition number: 2
  • Pages: 240
  • Product dimensions: 8.50 (w) x 11.00 (h) x 0.60 (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

About the Authors

Chapter 1: Documenting the Occupational Therapy Process
Chapter 2: The Health Record
Chapter 3: Using Medical Terminology
Chapter 4: Avoiding Common Documentation Mistakes
Chapter 5: Writing the "S"—Subjective
Chapter 6: Writing the "O"—Objective
Chapter 7: Tips for Writing a Better "O"
Chapter 8: Writing the "A"—Assessment
Chapter 9: Writing the "P"—Plan
Chapter 10: Special Situations and SOAP Analysis
Chapter 11: Goals and Interventions
Chapter 12: Evaluation and Intervention Planning
Chapter 13: Documenting Different Stages of Treatment
Chapter 14: Documentation in Different Practice Settings
Chapter 15: Making Good Notes Even Better
Chapter 16: Examples of Different Kinds of Notes

Appendix: Suggestions for Completing the Worksheets
SOAP Notes Checklist

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