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Doody's Review ServiceReviewer: Brent H. Braveman, MEd, OTR/L(University of Illinois at Chicago)
Description: This workbook is intended as a teaching tool to assist with the instruction of documentation. It is focused on the SOAP (subjective, obective, assessment, and plan) format of medical documentation and includes chapters dedicated to each section of the SOAP note in addition to chapters on medical terminology and the use of abbreviations. Each chapter includes several worksheets in addition to the text.
Purpose: This book is intended to function as an instructional aide in teaching documentation using the SOAP note format. This is an area that is time-consuming and is often problematic for students and instructors.
Audience: Academic clinical faculty and clinical fieldwork educators will find this to be a valuable resource. It is an appropriate guide for students or may serve as a review tool for entry-level therapists. It is also appropriate for use by occupational therapists, physical therapists, or other disciplines that use the SOAP format.
Features: Features of this book include worksheets in each chapter to allow practice and that might facilitate out-of-class work by students. Answers to each worksheet are included to reinforce learning. Appendixes on documenting for third-party payers and a summary of SOAP note contents are useful.
Assessment: This is a useful introductory text that would be appropriate for use with undergraduates, fieldwork students, and entry-level therapists. It is formatted in a reader-friendly manner in short but complete chapters. It is highly recommended to both faculty and students.