Documentation Manual For Writing Soap Notes In Occupational Therapy

Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition presents a systematic approach to a standard form of health care documentation: the SOAP note.

Manual focusing on documenting the occupational therapy process. Each skill is broken down into small steps and taught individually. Includes a template for writing problems, goals, and each section of the SOAP note. Also includes practice worksheets and detachable checklist and summary.

Rev. ed. of: Documentation manual for writing SOAP notes in occupational therapy / Sherry Borcherding. 2nd ed. c2005.

Teaches the mechanics of writing problem statements and goals, and addressing documentation in different stages of treatment and practice settings.

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.

-- Chapter on the development and use of forms and documentation-- Coverage of computerized documentation-- Thorough updating, including a discussion of the managed care environment and Medicare-- Additional exercises and examples-- Perforated worksheets-- Basic note-writing rules, including the POMR method, are reviewed-- Examples provided of both correct and incorrect note writing

Fully revised to reflect the latest AOTA standards, Occupational Therapy Evaluation for Children: A Pocket Guide, 2nd Edition is a comprehensive, portable reference that provides occupational therapists a trusted resource for use throughout their education and into practice. Unique and easy-to-use, this proven book provides an overview of theory, as well as step-by-step coverage of techniques. Clinical examples illustrate the application of content, as well as client and family-centered practice; illustrations demonstrate assessment techniques; and extensive tables summarize key assessments, techniques, and actions. This updated Second Edition includes new assessment tools, new content addressing specialty areas such as autism, additional assessments, and more.

Fully revised to re flect the latest AOTA standards, Occupational Therapy Evaluation for Adults: A Pocket Guide, 2nd Edition is a quick, comprehensive reference to guide students and practitioners as they perform efficient evaluations of adults, identify problems, and plan and implement interventions to produce optimal therapeutic outcomes. Clinical examples illustrate the application of content, illustrations demonstrate assessment techniques, and extensive tables capture information in an easy-to-read manner. This completely revised and updated Second Edition covers a wide range of new assessments and tools for community-based practitioners, includes up-to-coverage of assessing clients in natural settings, and offers a strong focus on helping readers develop practical skills for the workplace.