Documentation Manual for Writing SOAP Notes in Occupational Therapy

This exciting new manual presents a systematic approach to writing one form of documentation, the SOAP note. The purpose of this text is to teach readers to write SOAP notes that will be reimbursable under Medicare, Part B, and managed care. With the current changes in healthcare, documentation of patient care is essential to meet standards for reimbursement of services.

SOAP notes prepare students for real-world clinical practice, effectively teaching the mechanics of writing problem statements and goals, and addressing documentation in different stages of treatment and practice settings. The author walks the reader through each step of the documentation process, effectively teaching the mechanics of writing problem statements and goals and addressing documentation in different stages of treatment and practice settings.

Written in a manual format, this book provides the reader with: A step-by-step “how to” approach to documenting the occupational therapy process. Skills broken down into small steps and taught individually. A format or “template” for writing problems, goals, and each section of the SOAP note. A list of common abbreviations and symbols used in documentation. Examples of notes from many practice areas and stages of the documentation process. Worksheets that provide quick checklist and summary that can be carried into clinical situations to remind the reader of the essential requirements for SOAP notes.

Documentation Manual for Writing SOAP Notes in Occupational Therapy is the only manual that teaches a skill focusing on the specific requirements of OT application, and then provides the opportunity for practice with exercises and examples presented throughout the book.