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.

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.

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. 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.

PREPARE YOUR OT STUDENTS TO BECOME OT THINKERS. Thoroughly revised and updated, the 4th Edition of this groundbreaking text traces the historical development of the foundations of modern occupational therapy theory; examines its status today; and looks to its future. Dr. Kielhofner compares and contrasts eight well-known models, using diagrams to illustrate their practical applications and to highlight their similarities and differences. Well organized chapters are supported by extensive references.

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.

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.

Although Outcome Measurement has become an important tool in the evaluation of health promotion patient education and other health services interventions, problems remain in locating reliable measurements and scales. This book provides a unique compilation of more than 50 self-administered scales for measuring health behaviors, health status, self-efficacy, and health-care utilization.