Writing SOAP Notes: With Patient/Client Management Formats / Edition 3

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Ginge Kettenbach’s revision teaches students and new practitioners the basic skills needed to write two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and Patient/Client Management forms. This updated edition includes even more exercises to help students learn how to write clear, concise, and correct patient care notes. Worksheets at the end of each note section encourage clinical decision making on the information they have just learned. Rationales are given for all decisions.


  • New chapters offer background and instruction on the emerging Patient/Client Management format so students will know how to write patient care notes as alternative formats develop
  • Updated to incorporate the uniform terminology of the APTA's Guide to Physical Therapist Practice into relevant, usable formats consistent with today’s emphasis on evidence-based practice
  • Examples, especially on the "A" part of the notes, refer to the diagnostic categories in the Guide and strengthen students’ ability to communicate more effectively with other members of a patient/client’s health-care team
  • Examples include more home care and outpatient cases in line with the trend to shorten or eliminate inpatient treatments
  • Additional exercises and examples help students sharpen the decision-making and writing skills needed to prepare good medical reports
  • Coverage of Medicare forms and computerized documentation
  • Basic note-writing rules, including the POMR method, are reviewed
  • Samples provided of both correct and incorrect note writing

The book contains no figures.

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Editorial Reviews

From The Critics
Reviewer: 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.
Designed to sharpen the decision-making and writing skills needed to prepare good medical reports using the SOAP method. Provides ample practice worksheets and reviews standard abbreviations and note-writing rules, including the POMR method. Lacks an index. Annotation c. Book News, Inc., Portland, OR (booknews.com)

3 Stars from Doody
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Product Details

  • ISBN-13: 9780803608368
  • Publisher: F. A. Davis Company
  • Publication date: 10/27/2003
  • Edition description: Subsequent
  • Edition number: 3
  • Pages: 256
  • Product dimensions: 8.28 (w) x 11.22 (h) x 0.47 (d)

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Sort by: Showing all of 2 Customer Reviews
  • Anonymous

    Posted August 1, 2005

    SOAP vs HEAL

    I would have named the book 'Writing HEAL Notes'... The SOAP acronym in that it describes the 4-step approach to patient processing in a physician's office. Might I suggest that, especially in this case, HEAL might be a better acronym. Whereas SOAP is an abbreviation for Subjective, Objective, Assessment and Plan, HEAL stands for History, Exam, Assessment and Layout. The latter is simply a different way of conveying the same 4-step approach. Michael Harvell CRCI@NorthState.net

    Was this review helpful? Yes  No   Report this review
  • Anonymous

    Posted May 29, 2010

    No text was provided for this review.

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