The OTA's Guide to Writing SOAP Notes PDF Download
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Author: Sherry Borcherding
Publisher: SLACK Incorporated
ISBN: 9781556427794
Category : Medical
Languages : en
Pages : 244
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Book Description
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. 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.
Author: Sherry Borcherding
Publisher: SLACK Incorporated
ISBN: 9781556427794
Category : Medical
Languages : en
Pages : 244
Get Book Here
Book Description
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. 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.
Author: Ginge Kettenbach
Publisher: F A Davis Company
ISBN: 9780803608368
Category : Medical
Languages : en
Pages : 215
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Book Description
Ginge Kettenbach's workbook leads you through the process of learning two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and the Patient/Client Management format. This updated 3rd edition includes hands-on exercises and examples to help you sharpen the writing skills that you will need to prepare clear, concise, and accurate medical documentation. Worksheets at the end of each note section further strengthen your writing skills on the information you have just learned. Explanations of documentation that are consistent with the APTA's Guide to Physical Therapist Practice are given for all decisions. Book jacket.
Author: Ginge Kettenbach
Publisher: F. A. Davis Company
ISBN:
Category : Medical
Languages : en
Pages : 164
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Book Description
-- 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
Author: Ginge Kettenbach
Publisher: F.A. Davis
ISBN: 080365846X
Category : Medical
Languages : en
Pages : 295
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Book Description
Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with simple, straight forward explanations of the hows and whys of documentation. It also keeps pace with the changes in Physical Therapy practice today, emphasizing the Patient/Client Management and WHO’s ICF model.
Author: Ginge Kettenbach
Publisher: F. A. Davis Company
ISBN: 9780803600379
Category : Medical protocols
Languages : en
Pages : 0
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Book Description
-- 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
Author: Michael D. Reiter
Publisher: Taylor & Francis
ISBN: 1000896196
Category : Psychology
Languages : en
Pages : 302
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Book Description
This guide practically aids mental health professionals in understanding and improving their therapeutic and academic writing, demonstrating how the written word is an invaluable tool to document, assess, and promote change with those in and outside the therapy room. Exploring the various ways writing occurs in psychotherapy professions, Michael D. Reiter comprehensively covers the range of the written word, from progress notes and assessment documentation, to journaling and therapeutic letters, as well as contacting larger systems such as report writing and grant applications. Chapters are formatted to include the purpose and function of a particular type of writing before providing multiple examples so therapists can apply this in their own practice. This book aims to help all therapists, regardless of academic training or therapeutic modality, to incorporate these ideas into their work. This book is designed for mental health professionals in a variety of settings, including counselors, therapists, social workers, family therapists, and clinical psychologists. This book is useful for graduate students as well as those already in practice.
Author: Joanna C. Weaver
Publisher: Taylor & Francis
ISBN: 1040145035
Category : Education
Languages : en
Pages : 187
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Book Description
This resource offers teachers a simple framework to seamlessly add reflective practice to their day and encourages educators to critically reflect on instructional planning and practice. Commonly used in other busy professions, the SOAP Notes structure makes it easy to reflect on student progress through any lesson or learning activity, regardless of grade band or content area. Each category—Subjective, Observation, Assessment, and Planning—allows for documentation of obstacles, difficulties, or challenges within a lesson so educators can address these concerns in subsequent lessons. Each chapter features an in-service teacher who used SOAP Notes reflections in their classrooms to improve their instruction and student learning. Contributors are from diverse teaching backgrounds, schools, and student populations. The authors include instructions for using the template in a variety of scenarios, blank worksheets, completed SOAP examples, and important take-aways. Whether there is an hour or only minutes in the day to focus on reflective practice, these teachers demonstrate how this framework makes this activity possible in any classroom. Ideal for preservice and in-service teachers, administrators, and other education professionals across K–12 settings, this accessible read demonstrates the ease of reflective practice while celebrating teacher voices. This simple structure makes adding reflection and intention to teachers’ routine immediately doable.
Author: Lori Quinn
Publisher: Elsevier Health Sciences
ISBN: 0323312330
Category : Medical
Languages : en
Pages : 289
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Book Description
Better patient management starts with better documentation! Documentation for Rehabilitation: A Guide to Clinical Decision Making in Physical Therapy, 3rd Edition shows how to accurately document treatment progress and patient outcomes. Designed for use by rehabilitation professionals, documentation guidelines are easily adaptable to different practice settings and patient populations. Realistic examples and practice exercises reinforce concepts and encourage you to apply what you've learned. Written by expert physical therapy educators Lori Quinn and James Gordon, this book will improve your skills in both documentation and clinical reasoning. A practical framework shows how to organize and structure PT records, making it easier to document functional outcomes in many practice settings, and is based on the International Classification for Functioning, Disability, and Health (ICF) model - the one adopted by the APTA. Coverage of practice settings includes documentation examples in acute care, rehabilitation, outpatient, home care, and nursing homes, as well as a separate chapter on documentation in pediatric settings. Guidelines to systematic documentation describe how to identify, record, measure, and evaluate treatment and therapies - especially important when insurance companies require evidence of functional progress in order to provide reimbursement. Workbook/textbook format uses examples and exercises in each chapter to reinforce your understanding of concepts. NEW Standardized Outcome Measures chapter leads to better care and patient management by helping you select the right outcome measures for use in evaluations, re-evaluations, and discharge summaries. UPDATED content is based on data from current research, federal policies and APTA guidelines, including incorporation of new terminology from the Guide to Physical Therapist 3.0 and ICD-10 coding. EXPANDED number of case examples covers an even broader range of clinical practice areas.
Author: M.N. Hegde
Publisher: Plural Publishing
ISBN: 1635504635
Category : Medical
Languages : en
Pages : 433
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Book Description
With major content updates and enhanced supporting online materials, the seventh edition of Clinical Methods and Practicum in Speech-Language Pathology remains an essential resource for students in speech-language pathology who are about to begin their clinical practicum. The text is a comprehensive source of information that will help establish clear expectations for both student clinicians and clinical supervisors. It is hoped that students who read this book prior to starting their clinical practicum will be better prepared to meet the exciting and yet often challenging task of providing ethical and effective services to children and adults with communication disorders. Readers will gain an understanding of the structure of different clinical practicum sites; principles of ethical practices; conduct, behavior, and competencies expected of them; justifiable expectations of their clinical supervisors; and the many fundamental principles of assessment and intervention across most disorders of communication. The book is divided into two sections: clinical practicum and clinical methods in speech-language pathology. These sections provide coverage of the structural and functional aspects of clinical practicum in a variety of settings. The author emphasizes that clinical practicum is an exciting learning experience. The students will understand what is expected of them in each setting and what they can expect from their clinical supervisors. An overview of treatment methods that apply across disorders is also included. New to the Seventh Edition: * Two new chapters: * Chapter 5 on assessment, which includes a sample assessment report * Chapter 6 on clinical reports, treatment plans, and data documentation * The clinical methods sections include new and expanded information on assessment, target behaviors, and treatment strategies for all disorders of communication * The section on clinical practicum in public schools has been expanded to reflect the current guidelines and practices * Infused multicultural issues into all relevant chapters and consequently eliminated a separate chapter on the topic * Updated information on ASHA’s new or current requirements and guidelines for clinical practicum and certification in speech-language pathology * Expanded and updated ASHA guidelines on telepractice * Summary of ASHA’s latest position on the qualifications of clinical supervisors * Information on the qualifications and scope of practice of speech-language pathology assistants in various settings * Added chapter summary questions so students can assess their understanding of the material Key Features: * Outlines open each chapter and provide a summary of the key topics * A comprehensive glossary allows readers to easily find and define important terms or concepts * Bulleted and boxed information for easy access Disclaimer: Please note that ancillary content such as printable forms and reports are not included as in the original print version of this work.
Author: Michael A. Arntfield
Publisher: Broadview Press
ISBN: 1554812291
Category : Language Arts & Disciplines
Languages : en
Pages : 250
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Book Description
Notable for its use of real document examples drawn from actual healthcare settings, in addition to its central section’s extended focus on narrative medicine and new media writing, Healthcare Writing: A Practical Guide to Professional Success provides a wide-ranging, much-needed contemporary perspective on the modes and contexts of writing most pertinent to today’s healthcare professionals. Aimed at students enrolled in university- or college-level healthcare programs, healthcare communication specialists, as well as at current clinical practitioners seeking a portable reference and guide, this book combines a detailed discussion of approaches to key healthcare document types—both professional and academic—with a thorough but accessible overview of essential points of grammar, punctuation, and style.
