000 02447cam a2200289 4500
001 1617110825
008 151214t2013 xxu||||| |||| 00| 0 eng d
020 _a1617110825
100 _aMorreale, Marie J.
245 4 _aThe OTA's guide to documentation : writing SOAP notes
250 _a3rd ed.
260 _aThorofare, NJ :
_bSLACK
_cc2013
300 _a225 p. : ill. ; 28 cm.
500 _aOccupational therapy assistant's guide to documentation
500 _aRev. ed. of: The OTA's guide to writing SOAP notes. 2nd ed. 2007.
500 _aOTA's guide to writing SOAP notes."
505 _aDocumenting the occupational therapy process -- The health record -- Billing and reimbursement -- Using medical terminology -- Avoiding common documentation mistakes -- Writing the ""S"" subjective -- Writing the ""O"" objective -- Tips for writing a better ""O"" -- Writing the ""A"" assessment -- Writing the ""P"" plan -- Documenting special situations -- Improving observation skills and refining your note -- Making good notes even better -- Evaluation and intervention planning -- Goals and interventions -- Documenting different stages of treatment -- Documentation in different practice settings -- Examples of different kinds of notes.
520 _a""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. 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 are also available online with answers included to enable independent study.""-- Back cover.
520 _aIncludes bibliographical references and index.
650 _aPractice of Medicine
690 _aOccupational therapy assistants
690 _aMedical records
690 _aOccupational Therapy-methods
690 _aDocumentation-methods
690 _aMedical Records
700 _aBorcherding, Sherry
999 _c83823
_d83823