The OTA's Guide to Writing SOAP Notes PDF Download

Author: Sherry Borcherding
Publisher: SLACK Incorporated
ISBN: 9781556427794
Category : Allied health personnel
Languages : en
Pages : 244

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Book Description
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. "Answers" are provided for all worksheets so that the text can be used for independent study if desired. 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.

Author: Jeremiah Fleenor
Publisher: Mdpocket
ISBN: 9780977955923
Category : Medical
Languages : en
Pages : 0

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Book Description
A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), Objective (what the recorder observes), Assessment (recorder's summation), Plan (recorder's actions, based on the assessment).

Author: Mia Erickson
Publisher: SLACK Incorporated
ISBN: 9781556427824
Category : Medical records
Languages : en
Pages : 228

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Book Description
Complete & accurate documentation is one of the essential skills for a physical therapist. This book covers all the fundamentals & includes practice exercises & case studies throughout.

Author: Robert C. Schenck
Publisher: Jones & Bartlett Learning
ISBN: 9780892031726
Category : Education
Languages : en
Pages : 950

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Book Description
The third edition of Athletic Training and Sports Medicine is more specifically tailored to the needs of practising athletic trainers and primary care physicians, although educators should find it a useful reference for students. Many of the chapters from the second edition are supplemented and enhanced by new chapters. The major topics covered include: legal issues in sports medicine; injury prevention; evaluating the athlete; physiology of the musculoskeletal system; applied principles in treatment and rehabilitation; the anatomy and physiology of the musculoskeletal system; sports psychology; medical conditions; gender specific conditions; and athletes with different abilities.

Author: Kenneth L. Knight
Publisher: Lippincott Williams & Wilkins
ISBN: 9780781757447
Category : Medical
Languages : en
Pages : 448

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Book Description
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.

Author: Peter S. Uzelac
Publisher: Lippincott Williams & Wilkins
ISBN: 9781405104357
Category : Medical
Languages : en
Pages : 174

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Book Description
SOAP for Obstetrics and Gynecology features over 60 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar "SOAP" note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem, not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a "must-have" to keep in their white coat pockets for wards and clinics.

Author: Daniel Maldonado
Publisher: Lippincott Williams & Wilkins
ISBN: 1496397975
Category : Medical
Languages : en
Pages : 256

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Book Description
Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar "SOAP" note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation.

Author: Mark Kauffman
Publisher: Jones & Bartlett Learning
ISBN: 0763776548
Category : Medical
Languages : en
Pages : 303

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Book Description
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.

Author: Michael Koplen
Publisher: Masters in Massage Institute
ISBN: 9780999627075
Category :
Languages : en
Pages : 78

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Book Description
This course navigates Massage Therapists through the standard-accepted, docotr-apporved ways to take SOAP notes so you feel fully empowered with this skill-set!

Author: Jonathan K. Ehrman
Publisher: Human Kinetics
ISBN: 9780736065658
Category : Medical
Languages : en
Pages : 720

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Book Description
Clinical Exercise Physiology, Second Edition, provides a comprehensive look at the clinical aspects of exercise physiology by thoroughly examining the relationship between exercise and chronic disease. Updated and revised, this second edition reflects important changes that have occurred in the field since the first edition was published. It will provide professionals and students with fundamental knowledge of disease-specific pathology and treatment guidelines while also guiding readers through the clinical exercise physiology associated with exercise testing and training of patients with a chronic disease. The second edition of Clinical Exercise Physiologybuilds on information presented in the previous edition with reorganized chapters, updated and revised content, and the latest information on the key practice areas of clinical exercise physiology: endocrinology, the metabolic system, the cardiovascular system, the respiratory system, oncology, the immune system, bone and joint health, and the neuromuscular system. This second edition also features an online ancillary package, allowing instructors to more effectively convey the concepts presented in the text and prepare students for careers in the field. Clinical Exercise Physiology, Second Edition, is easy to navigate--the logical order of the chapters makes key information easy to find. The detailed chapters discuss 23 disease states and conditions that clinical exercise physiologists encounter in their work and provide guidance for the expert care of the populations discussed. Each chapter covers the scope of the condition; its physiology and pathophysiology and treatment options; clinical considerations, including the administration of a graded exercise test; and exercise prescription. The text also details how clinical exercise physiologists can most effectively address issues facing special populations, including children, the elderly, and female athletes. This comprehensive resource is an asset to new and veteran clinical exercise physiologists as well as those preparing for the ACSM Registry Examination. A must-have study tool for examination candidates, this text is on the suggested readings lists for both the Exercise Specialist and Registered Exercise Physiology exams. The text specifically addresses the knowledge, skills, and abilities (KSAs) listed by the ACSM for each of these certifications. Clinical Exercise Physiology, Second Edition, is the definitive resource on the use of exercise training for the prevention and treatment of clinical diseases and disorders. It includes the following features: -Revised and updated content reflects the recent changes in exercise testing and training principles and practices. -Four new chapters on depression and exercise, metabolic syndrome, cerebral palsy, and stroke are evidence of how the field has evolved in considering patients with more widely diagnosed diseases and conditions. -A new text-specific Web site containing a test package and PowerPoint presentation package helps instructors present the material from the book. -Case studies provide real-world examples of how to use the information in practice. -Discussion questions that highlight important concepts appear throughout the text to encourage critical thinking. -Practical application boxes offer tips on maintaining a professional environment for client-clinician interaction, a literature review, and a summary of the key components of prescribing exercise. Clinical Exercise Physiology, Second Edition, is the most up-to-date resource for professionals looking to enhance their knowledge on emerging topics and applications in the field. It is also a valuable text for students studying for the ACSM Registry Examination.