SOAP Notes

SOAP Notes
Author: Jeremiah Fleenor
Publisher: Mdpocket
Total Pages: 0
Release: 2007-03
Genre: Medical
ISBN: 9780977955923

A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), Objective (what the recorder observes), Assessment (recorder's summation), Plan (recorder's actions, based on the assessment).

The OTA's Guide to Writing SOAP Notes

The OTA's Guide to Writing SOAP Notes
Author: Sherry Borcherding
Publisher: SLACK Incorporated
Total Pages: 244
Release: 2007
Genre: Allied health personnel
ISBN: 9781556427794

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.

Writing Patient/Client Notes

Writing Patient/Client Notes
Author: Ginge Kettenbach
Publisher: F.A. Davis
Total Pages: 295
Release: 2016-05-11
Genre: Medical
ISBN: 080365846X

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.

Documentation Manual for Writing SOAP Notes in Occupational Therapy

Documentation Manual for Writing SOAP Notes in Occupational Therapy
Author: Sherry Borcherding
Publisher: Slack Incorporated
Total Pages: 236
Release: 2005
Genre: Medical
ISBN: 9781556427190

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.

Writing SOAP Notes

Writing SOAP Notes
Author: Ginge Kettenbach
Publisher: F A Davis Company
Total Pages: 215
Release: 2003
Genre: Medical
ISBN: 9780803608368

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.

SOAP for the Rotations

SOAP for the Rotations
Author: Peter S. Uzelac
Publisher: Lippincott Williams & Wilkins
Total Pages: 663
Release: 2019-07-11
Genre: Medical
ISBN: 1975107667

Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient’s clinical problem, not the diagnosis, the book’s at-a-glance, two-page layout uses the familiar SOAP note format.

Guide to Clinical Documentation

Guide to Clinical Documentation
Author: Debra Sullivan
Publisher: F.A. Davis
Total Pages: 301
Release: 2011-12-22
Genre: Medical
ISBN: 0803629974

Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.

Note Designer

Note Designer
Author: Patricia C Baldwin
Publisher: Mindhabits Incorporated
Total Pages: 76
Release: 2016-03-23
Genre:
ISBN: 9780995063402

This book provides step-by-step guidelines, tips, and instruction on how to create and write psychotherapy treatment notes. Information and guidance are provided on how to write a treatment intake report, treatment progress notes, and termination summary. A number of sample notes, reports and templates are provided. The book also includes hundreds of representative statements for therapists to use in the design of their own psychotherapy progress notes. A valuable resource for experienced mental health professionals and trainees alike, from the creator of Note Designer therapy note-writing software. ""A time-saving reference to capture the essence and the methods of professional note writing for psychotherapists. Easy to apply and great to keep close-by when writing reports and progress notes."" --Alexandre Smith-Peter, Psy.D. candidate

Writing in the Health Professions

Writing in the Health Professions
Author: Barbara Heifferon
Publisher: Pearson
Total Pages: 340
Release: 2005
Genre: Language Arts & Disciplines
ISBN:

Practical, applied, and up-to-the-minute, Writing for the Health Professions teaches students, healthcare professionals, and professional writers the essential skills in medical and health communications. Drawing on her extensive experience as a nurse, cardio-pulmonary technician, medical writer, and writing teacher, Barbara Heifferon addresses the communications requirements of the healthcare professions and those who write in these high-tech fields. This comprehensive text covers writing situations and documents common in hospitals, clinics, HMOs, health insurance companies, public health campaigns, and other healthcare environments. Special attention is given to visual and electronic forms of communication, including Web sites and multimedia productions.