The Ota's Guide To Documentation: Writing Soap Notes by Marie MorrealeThe Ota's Guide To Documentation: Writing Soap Notes by Marie Morreale

The Ota's Guide To Documentation: Writing Soap Notes

byMarie Morreale, Sherry BorcherdingEditorMarie Morreale

Paperback | April 15, 2013

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With the current changes in health care, proper documentation of client care is essential in meeting the legal, ethical, and professional standards for reimbursement of services. Written specifically for occupational therapy assistants,The OTA's Guide to Documentation: Writing SOAP Notes, Third Editioncontains the step-by-step instruction needed to learn the documentation required for occupational therapy clinical practice and reimbursement.

Written in an easy-to-read format, thisThird Editionby Marie J. Morreale and Sherry Borcherding allows occupational therapy assistants to learn the purpose and standards of documentation throughout all stages of the occupational therapy process and in a variety of practice settings.

New features in theThird Edition:

· Incorporation of theOccupational Therapy Practice Framework: Domain and Process, Second Editionalong with other updatedAmerican Occupational Therapy Associationdocuments

· Electronic documentation information

· Information onInternational Classification of Functioning, Disability, and Healthlanguage

· Information on narrative notes with examples

· A new chapter on “Billing and Reimbursement with a focus on funding sources and requirements

· More information and examples for pediatric, school-based, and mental health practice settings

· Information on quality measures

· New worksheets for developing occupational therapy goals

· Additional worksheets on documentation mistakes and basics of documentation

· A new method of goal writing (COAST)

· Lists of professional language

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.

Instructors in educational settings can visitwww.efacultylounge.comfor additional material to be used in the classroom.

The OTA's Guide to Documentation: Writing SOAP Notes, Third Editionoffers both the necessary instruction and multiple opportunities to practice. 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 in thisThird Editionare available online, with answers included to enable independent study. Occupational therapy assistant students and faculty as well as practicing occupational therapy assistants and rehabilitation professionals will appreciate this valuable text.

As a bonus:

When you purchase a new copy ofThe OTA's Guide to Documentation: Writing SOAP Notes, Third Edition, you will receive access to scenario-based videos to practice the documentation process.


Marie J. Morreale, OTR/L, CHTis an adjunct faculty member at Rockland Community College, State University of New York. She has been teaching students in the Occupational Therapy Assistant Program there since 1998. Marie's courses include Professional Issues and Documentation, OT Skills, Geriatric Principles, and Advanced OT Skills. Ear...
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Title:The Ota's Guide To Documentation: Writing Soap NotesFormat:PaperbackDimensions:240 pages, 11 × 8.5 × 1.5 inPublished:April 15, 2013Publisher:Slack IncorporatedLanguage:English

The following ISBNs are associated with this title:

ISBN - 10:1617110825

ISBN - 13:9781617110825

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Table of Contents

Dedication
Acknowledgments
About the Authors


Chapter 1 Documenting the Occupational Therapy Process
Chapter 2 The Health Record
Chapter 3 Billing and Reimbursement
Chapter 4 Using Medical Terminology
Chapter 5 Avoiding Common Documentation Mistakes
Chapter 6 Writing the “S—Subjective
Chapter 7 Writing the “O—Objective
Chapter 8 Tips for Writing a Better “O
Chapter 9 Writing the “A—Assessment
Chapter 10 Writing the “P—Plan
Chapter 11 Documenting Special Situations
Chapter 12 Improving Observation Skills and Refining Your Note
Chapter 13 Making Good Notes Even Better
Chapter 14 Evaluation and Intervention Planning
Chapter 15 Goals and Interventions
Chapter 16 Documenting Different Stages of Treatment
Chapter 17 Documentation in Different Practice Settings
Chapter 18 Examples of Different Kinds of Notes References

Appendix: Suggestions for Completing the Worksheets
Index