The OTA's guide to documentation : writing SOAP notes

Occupational therapy assistant's guide to documentation

Rev. ed. of: The OTA's guide to writing SOAP notes. 2nd ed. 2007.

OTA's guide to writing SOAP notes."

Documenting the occupational therapy process -- The health record -- Billing and reimbursement -- Using medical terminology -- Avoiding common documentation mistakes -- Writing the ""S"" subjective -- Writing the ""O"" objective -- Tips for writing a better ""O"" -- Writing the ""A"" assessment -- Writing the ""P"" plan -- Documenting special situations -- Improving observation skills and refining your note -- Making good notes even better -- Evaluation and intervention planning -- Goals and interventions -- Documenting different stages of treatment -- Documentation in different practice settings -- Examples of different kinds of notes.

""This text teaches the SOAP notes format reimbursable by Medicare Part B and other third-party payers. Other topics include a review of spelling and grammar, an overview of the initial evaluation process delineating the roles of the occupational therapist and the occupational therapy assistant, tips for clinical reasoning, and guidelines for selecting appropriate interventions. Templates allow beginning students to practice formatting SOAP notes, and a detachable summary sheet can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Multiple worksheets are provided for practice in developing observation skills, clinical reasoning, documentation skills, and a repertoire of professional language. All worksheets are also available online with answers included to enable independent study.""-- Back cover.

Includes bibliographical references and index.