Documentation Manual for Occupational Therapy: Writing Soap Notes

ISBN-13: 9781630912314 / Angielski / Miękka / 2016 / 280 str.

Crystal Gateley; Sherry Borcherding

Opis

One of the most critical skills that occupational therapists must learn is effective documentation.

With that idea in mind, 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. The clinical reasoning skills underlying SOAP note documentation can be adapted to fit the written or electronic documentation requirements of nearly any occupational therapy practice setting.

This new Fourth Edition has been updated to reflect current information essential to contemporary occupational therapy practice, including the AOTA's Occupational Therapy Practice Framework: Domain & Process, Third Edition.

Documentation Manual for Occupational Therapy, Fourth Edition also includes the COAST method, a specific format for writing occupation-based goals.

Crystal Gateley and Sherry Borcherding use a "how-to" strategy by breaking up the documentation process into a step-by-step sequence. Numerous worksheets are provided to practice each individual skill as well as the entire SOAP note process. In addition, examples from a variety of practice settings are included as a reference. Although this text addresses documentation in occupational therapy practice, the concepts can be generalized across other health care disciplines as well.

New in the Fourth Edition:

• The chapter focusing on reimbursement, legal, and ethical considerations has been vastly expanded to provide an overview of sources of reimbursement, regulatory guidelines, and legal and ethical issues.
• A new chapter focusing on electronic documentation has been added to illustrate how the concepts presented in this text can be used in various electronic documentation software products.
• Faculty will have access to 12 videos that can be used for instructional purposes and documentation practice.
• This edition includes an expanded Instructor's Manual with sample quiz questions for several of the chapters, templates and grading rubrics for documentation assignments, and other instructional resources.

Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom.

Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition presents essential documentation skills that all occupational therapy clinicians, faculty, and students will find critical for assessing, treating, and offering the best evidence available for their clients.

Spis treści

Dedication
Acknowledgments
About the Authors
 
Chapter 1           Documenting the Occupational Therapy Process
Chapter 2           The Health Record
Chapter 3           Reimbursement, Legal, and Ethical Considerations
Chapter 4           General Guidelines for Documentation
Chapter 5           Writing Occupation-Based Problem Statements
Chapter 6           Writing Measurable Occupation-Based Goals and Objectives
Chapter 7           Writing the “S”—Subjective
Chapter 8           Writing the “O”—Objective
Chapter 9           Writing the “A”—Assessment
Chapter 10        Writing the “P”—Plan
Chapter 11        Making Good Notes Even Better
Chapter 12        Intervention Planning
Chapter 13        Documenting Different Stages of Service Delivery
Chapter 14        Documentation in Different Practice Settings
Chapter 15        Electronic Documentation
Chapter 16        Examples of Different Kinds of Notes
 
Appendix: Suggestions for Completing the Worksheets
Index