Product 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.
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.
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.
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Contents
Dedication
Acknowledgments
About the Author
Chapter 1:
Documenting the Occupational Therapy Process
Chapter 2: The Health
Record
Chapter 3: Writing Functional Problem Statements
Chapter 4:
Writing Functional and Measurable Goals and Objectives
Chapter 5: Writing
the "S"---Subjective
Chapter 6: Writing the "O"--Objective
Chapter 7:
Writing the "A"--Assessment
Chapter 8: Writing the "P"--Plan
Chapter 9:
Intervention Planning
Chapter 10: Documenting Different Stages of
Treatment
Chapter 11: Documentation in Different Practice
Settings
Chapter 12: Making Good Notes Even Better
Chapter 13: Examples
of Different Kinds of Notes
References
Appendix: Suggestions
for Completing the Worksheets
Index
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Reviews
Reviews from previous edition:
"…excellent book on writing SOAP notes."
— Aimee J. Luebben, EdD, OTR/L, FAOTA, Special Interest Section Quarterly, AOTA
"This manual is an excellent compilation of information needed to teach SOAP note documentation to occupational therapists.”
— Al Copolillo, PhD, OTR/L, Occupational Therapy in Health Care
"(This book) is clearly written and quite thorough. It would be of most benefit to students or those therapists needing to refresh or learn the SOAP method of documentation."
— Pam Harris, Canadian Journal of Occupational Therapy
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About the Editor
Sherry Borcherding currently serves as a faculty member at University of Missouri–Columbia, a Carnegie Research Extensive University, where she has taught since 1992. She teaches disability awareness, complementary therapy, and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. She has also taught clinical ethics, frames of reference, psychopathology, loss and disability, long-term care, and wellness. Two of her courses are designated as campus writing courses and one is credentialed for computer and information proficiency. Sherry is frequently invited to present on collaborative learning, peer review, and educational technology.
Sherry graduated with honors from Texas Woman’s University with a BS in occupational therapy and went on to complete her master's in special education with special faculty commendation at George Peabody College in Nashville, TN. Following her staff positions in rehabilitation, home health, and pediatrics, she assumed a number of management roles including Chief Occupational Therapist at East Texas Treatment Center, Director of Occupational Therapy at Mid-Missouri Mental Health Center, and Director of Rehabilitation Services at Transitional Housing Agency. She has also planned, designed, and directed occupational therapy programs at Capital Regional Medical Center in Jefferson City, MO and at Charter Behavioral Health Center in Columbia, MO.
Besides teaching, Sherry consults on quality assurance issues for local behavioral health centers and has a private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy at the techniques level through Upledger Institute and is attuned as a Reiki master. For leisure, Sherry enjoys folk dance, music, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past few years.
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