The OTA's Guide to Writing SOAP Notes
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...
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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. Booknews 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
Contents Dedication Acknowledgments About the AuthorsChapter 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 References Appendix: Suggestions for Completing the Worksheets Index SOAP Notes Checklist
\ 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 CriticsWritten 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\ \
