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

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

Pub. Date:
SLACK, Incorporated

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

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.

Product Details

ISBN-13: 9781556427794
Publisher: SLACK, Incorporated
Publication date: 12/01/2006
Edition description: Second
Pages: 240
Product dimensions: 8.50(w) x 11.00(h) x 0.60(d)

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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