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Documentation manual for occupational therapy : writing SOAP notes / Crystal A. Gateley, PHD, OTR/L, Associate Chair & Associate Teaching Professor, Department of Occupational Therapy, University of Missouri - School of Health Professions, Columbia, Missouri, Sherry Borcherding, MA, OTR/L, Clinical Associate Professor, Retired, University of Missouri, Columbia, Missouri.

By: Contributor(s): Material type: TextTextPublisher: Thorofare, NJ : SLACK Incorporated, [2017]Copyright date: ©2017Edition: Fourth editionDescription: 264 pages : illustrations ; 28 cmContent type:
  • text
Media type:
  • unmediated
Carrier type:
  • volume
ISBN:
  • 163091231X
  • 9781630912314
Other title:
  • Writing Subjective, Objective, Assessment, and Plan notes
  • Writing SOAP notes
  • Occupational therapy [Parallel title]
Subject(s): Genre/Form: Additional physical formats: No titleDDC classification:
  • 615.8515 23
LOC classification:
  • RM735.4 .B67 2017
Contents:
Dedication -- Acknowledgments -- About the Authors -- 1. Documenting the occupational therapy process -- 2. The health record -- 3. Reimbursement, legal, and ethical considerations -- 4. General guidelines for documentation -- 5. Writing measurable occupation-based problem statements -- 6. Writing measurable occupation-based goals and objectives -- 7. Writing the "S" subjective -- 8. Writing the "O" objective -- 9. Writing the "A" assessment -- 10. Writing the "P" plan -- 11. Making good notes even better -- 12. Intervention planning -- 13. Documenting different stages of service delivery -- 14. Documentation in different practice settings -- 15. Electronic documentation -- 16. Examples of different kinds of notes -- Appendix: Suggestions for Completing the Worksheets -- Index.
Summary: "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." --Publisher's website
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Holdings
Item type Current library Call number Copy number Status Date due Barcode
Book North Campus North Campus Main Collection 615.8515 GAT (Browse shelf(Opens below)) 1 Available A554889B
Book North Campus North Campus Main Collection 615.8515 GAT (Browse shelf(Opens below)) 1 Available A554917B
Book North Campus North Campus Main Collection 615.8515 GAT (Browse shelf(Opens below)) 1 Available A554139B
Book South Campus South Campus Main Collection 615.8515 GAT (Browse shelf(Opens below)) 1 Available A554893B

Preceded by Documentation manual for occupational therapy : writing SOAP notes / Crystal A. Gateley, Sherry Borcherding. 3rd ed. c2012.

Includes bibliographical references and index.

Dedication -- Acknowledgments -- About the Authors -- 1. Documenting the occupational therapy process -- 2. The health record -- 3. Reimbursement, legal, and ethical considerations -- 4. General guidelines for documentation -- 5. Writing measurable occupation-based problem statements -- 6. Writing measurable occupation-based goals and objectives -- 7. Writing the "S" subjective -- 8. Writing the "O" objective -- 9. Writing the "A" assessment -- 10. Writing the "P" plan -- 11. Making good notes even better -- 12. Intervention planning -- 13. Documenting different stages of service delivery -- 14. Documentation in different practice settings -- 15. Electronic documentation -- 16. Examples of different kinds of notes -- Appendix: Suggestions for Completing the Worksheets -- Index.

"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." --Publisher's website

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