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Documentation Manual for Writing SOAP Notes in Occupational Therapy

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Book Description: One of the most critical skills today’s occupational therapists will need to learn and master is documentation. The most successful workbook on the market to educate students and keep professionals sharp is Documentation Manual for Writing SOAP Notes in Occupational Therapy—now available in an improved and revised second edition.   This workbook successfully uses a “how to” approach to explain the critical skill of documentation.  By concentrating on the instruction of one essential skill and not diverging into other related areas, this new edition allows occupational therapists to focus completely on writing SOAP notes.   Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition is designed to break down the task of SOAP documentation into manageable units of skill sets. Sherry Borcherding has identified the concepts that are the most difficult to grasp and has incorporated new worksheets to help better understand these important terms.   The new edition of this indispensable workbook provides a better representation of the major practice settings in which occupational therapists are employed, including mental health and pediatric settings. Complementary therapies have also been included with examples of documentation for two common techniques, CranioSacral Therapy and Tai Chi.   New worksheets, revised chapters, and clinical examples ensure that Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition will be the only resource needed by occupational therapy students and professionals. Features of the Second Edition include: Documentation skills based on the concepts found in the Occupational Therapy Practice Framework. An explanation of The AOTA’s Guidelines for Documentation of Occupational Therapy Practice, including examples. A brief discussion of HIPAA, billing codes, and their importance in reimbursement. Detachable worksheets that walk students through the skills needed for successful documentation in the client’s health record. A detachable checklist to be used as a quick reference when evaluating your SOAP Note to ensure that all of the essential elements are included. Clinical examples that show a variety of successful wordings for each concept. Reorganized chapters that offer a user-friendly format and logical presentation of material.
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