Soap Note Samples
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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.
Therapeutic Modalities
Author: Kenneth L. Knight
language: en
Publisher: Lippincott Williams & Wilkins
Release Date: 2008
This user-friendly text, written in a clear and friendly manner by leading experts in the field, is intended primarily for undergraduate athletic training students. It encourages students to understand both the how and the why of therapeutic modality use so readers become thinking, decision-making professionals. It provides the knowledge needed to evaluate and select the most appropriate modality. All major modalities used to treat orthopedic injury and pain are covered, from electrotherapy to therapeutic heat and cold to therapeutic massage.
COMLEX Level 2-PE Review Guide
Author: Mark Kauffman
language: en
Publisher: Jones & Bartlett Learning
Release Date: 2010-10-25
COMLEX Level 2-PE Review Guide is a comprehensive overview for osteopathic medical students preparing for the COMLEX Level 2-PE (Performance Evaluation) examination. COMLEX Level 2-PE Review Guide covers the components of History and Physical Examination found on the COMLEX Level 2-PE The components of history taking, expected problem specific physical exam based on the chief complaint, incorporation of osteopathic manipulation, instruction on how to develop a differential diagnosis, components of the therapeutic plan, components of the expected humanistic evaluation and documentation guidelines. The final chapter includes case examples providing practice scenarios that allow the students to practice the cases typically encountered on the COMLEX Level 2-PE These practice cases reduce the stress of the student by allowing them to experience the time constraints encountered during the COMLEX Level 2-PE. This text is a one-of-a-kind resource as the leading COMLEX Level 2-PE board review book. • Offers practical suggestions and mnemonics to trigger student memory allowing for completeness of historical data collection. • Provides a method of approach that reduces memorization but allows fluidity of the interview and exam process. • Organizes the approach to patient interview and examination and provides structure to plan development. Describes the humanistic domain for student understanding of the areas being evaluated.