Nursing Soap Notes Examples

Modules for Basic Nursing Skills

The OTA's Guide to Writing SOAP Notes

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.

Smart Nursing

CE credit available through the No Dakota Nurses Association "Smoothly written and effectively blending hard facts and personal observations, the book is peppered with inspiring success stories about "what works" in terms of improving morale and the quality of nursing practice." Sean Clarke, RN, PhD, CRNP University of Pennsylvania School of Nursing "[Fabre's] not afraid to tackle the tough issues .Implementing Smart Nursing concepts will result in energy enhancing experiences for your nurses and better care for your patients." --Susan Keane Baker, MHA Author, Managing Patient Expectations Too many health care organizations are using short-term fixes to patient health care delivery problems. Patients, however, require long-term solutions that treat the whole person, not just their particular ailment. What the profession needs is Smart Nursing. Smart Nursing provides practical guidance on patient care that every nurse, manager, and health care facility can use to restore patient safety, generate revenue, reduce nurse turnover, and stimulate realistic health care solutions. In this new edition, Fabre presents the recently updated Smart Nursing model. This practical model uses seven basic elements to deliver improved results, improved patient care, and increased employee job satisfaction. These simple yet critical building blocks- caring, respect, simplicity, flexibility, integrity, communication, and professional culture-allow nurses to create a positive work environment, and provide holistic care to patients. Special Features: Provides practical, cost-effective solutions to business and management problems, such as strategies for improved staffing and retention Includes guidance on leadership and mentoring, building high-performance teams, and accelerating professional development Presents strategies and recommendations for developing strong relationships with staff for increased communication and efficiency