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.

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.

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.

Rev. ed. of: Documentation manual for writing SOAP notes in occupational therapy / Sherry Borcherding. 2nd ed. c2005.

Teaches the mechanics of writing problem statements and goals, and addressing documentation in different stages of treatment and practice settings.

This quick reference guide helps occupational therapy students and practitioners perform efficient and comprehensive evaluations for adults with disabilities. Designed to fit in the lab coat pocket, this book guides readers through the process of an evaluation. For easy reading, information in this spiralbound volume is organized into tables, boxes, and schematics. Features include: detailed appendices about standardized assessments and formal evaluation procedures; illustrated evaluation procedures; an evaluation checklist to help readers track each client's evaluation; suggestions for sequencing and abbreviating different evaluation procedures; and specific advice on meeting third-party payers' reimbursement requirements.

Written by and specifically for Occupational Therapy Assistants, The OTA's Guide to Writing SOAP Notes is an instruction manual for teaching a specific skill: documentation as required for reimbursement in occupational therapy. With the current changes in healthcare, documentation of patient care is essential to meet standards for reimbursement of services. The purpose of this new text is to teach the Occupational Therapy Assistant to write SOAP notes that will be reimbursable under Medicare Part B and managed care. Documentation is learned in the same way that any other skill is learned-instruction and practice. The OTA's Guide to Writing SOAP Notes is the only text that provides instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional new text 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 the SOAP note, 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. This new manual is a must-have for all Occupational Therapy Assistant students! Features: The only text that is written as a "how to" manual rather than as a philosophic treatise. Skills are broken down into small steps and taught as discrete units, allowing mastery of each segment before moving on. Many examples are provided for different stages of treatment, in a variety of practice settings. An appendix gives possible solutions to the worksheets, making the text useful for self-directed learning.