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As the practice of occupational therapy evolves, so too should the resources that aid clinicians, faculty, and students in learning and achieving the skill of effective documentation. Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Editionis designed to provide each part of the documentation process, while the worksheets are designed to let you practice each step as you learn it. Crystal A. Gateley and Sherry Borcherding take the Third Edition and broaden the scope of the text to include SOAP notes relevant to pediatric practice, driving assessment, balance, assistive technology, positioning and mobility, and other practice settings. Additionally, the authors have introduced in this updated edition, the COAST method of goal writing that emphasizes client-centered and occupation-based intervention and documentation. Also included in the Third Edition, new online instructor's material that includes videos, scenarios, corresponding documentation, sample grading rubrics, and assignments As in the previous editions, Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Editionfocuses specifically on documentation of client performance in occupational therapy practice. The proven ;how to ; strategy of this workbook translates the SOAP note process into a step-by-step sequence. Features of the Third Edition Include: " Worksheets designed to practice individual skills as well as the entire SOAP note process " New chapter on reimbursement, legal, and ethical consideration " New chapter on general guidelines for documentation " Instructor's material that includes videos, scenarios, corresponding documentation, sample grading rubrics, and assignments " Additional on-line resources available with new book purchase " Current information including AOTA's Centennial Vision, the Occupational Therapy Practice Framework: Domain & Process, 2nd Edition, and other AOTA Official Documents. Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom. Documentation Manual for Occupational Therapy, Third Editionpresents essential documentation skills that all occupational therapy clinicians, faculty, and students will find critical for when assessing, treating, and offering the best evidence available for their clients.
Table of Contents
Dedication Acknowledgments About the Authors Chapter 1 Documenting the Occupational Therapy Process Chapter 2 The Health Record Chapter 3 Reimbursement, Legal, and Ethical Considerations Chapter 4 General Guidelines for Documentation Chapter 5 Writing Functional Problem Statements Chapter 6 Writing Measurable Occupation-Based Goals and Objectives Chapter 7 Writing the \u201cS\u201d—Subjective Chapter 8 Writing the \u201cO\u201d—Objective Chapter 9 Writing the \u201cA\u201d—Assessment Chapter 10 Writing the \u201cP\u201d—Plan Chapter 11 Making Good Notes Even Better Chapter 12 Intervention Planning Chapter 13 Documenting Different Stages of Service Delivery Chapter 14 Documentation in Different Practice Settings Chapter 15 Examples of Different Kinds of Notes References Appendix: Suggestions for Completing the Worksheets Index