PDF-(READ)-Writing Patient/Client Notes: Ensuring Accuracy in Documentation

Master the hows and whys of documentationDevelop all of the skills you need to write clear concise and defensiblepatientclient care notes using a variety of tools including SOAP notesThis is the ideal resource for any health care professional needing to learn or improve their skillswith simple straight forward explanations of the hows and whys of documentation It also keeps pace with the changes in Physical Therapy practice today emphasizing the PatientClient Management and WHOs ICF modelSection by section youll learn how to document clearly and accurately while exercise by exercise youll practice mastering every step. Plymouth Healthcare NHS Trust. Catherine Bell, Joseph Clarke, Kyle Flegg, Matt Hill, Lauren Robbins and Kerri Tucker. Introduction. Good clinical records are crucial to patient care and safety. A consultation on the surgical ward round should take approximately ten minutes. However, the surgical ward-round does not often afford this amount of time per patient leading to a poor standard of documentation, which often does not reflect the doctor-patient consultation and may have medico-legal implications. documentation challenges since 2000. Services Offered. Zaetric offers technical writing, business process support and printing & binding services for the engineering, technical, and scientific fields.. Chapter 7. The Nursing Process: . Documenting the Nursing Process. Reference. Doenges. , M. E., & . Moorhouse. , M. F. (. 2008). . Application of nursing process and.  . nursing diagnosis: An interactive text for diagnostic reasoning. Cheryl Bernknopf R.N., BScN. Assistant Director Centauri Summer Camp. Co- Chair OCA Healthcare Committee. Board Member of the ACN. PURPOSE. To provide the multidisciplinary team with a structured note format for documenting. HPR . 451. Where does . documentation. fit into the TR process?. Assessment?. Planning??. Implementation???. Evaluation????. ??????????????????????????????????????. Documentation – who needs it?. TR/RT. reporting. nursing . informatics. Communication is Vital!. Technology is your friend!. Principles of Data Entry. Accurate:. Observations only. Do not use subjective words. Correct spelling, grammar & med terms. Trisha . Economidis. , MS, ARNP. Lake-Sumter Community College. What is a Health History?. Part of a comprehensive nursing assessment. Subjective data. Your Patient’s Story. Interviewing Techniques. RCPA Conference. October 8, 2014. Agenda . Behavioral Health Services Cultural Overview. Current Regulatory Environment – New Compliance Challenges. Function of the Progress Note. Defensive Maneuvers – Audit Proof Documentation. A documentation method used by health care providers . 4 parts. Subjective. Objective. Assessment. Plan. What is a SOAP Note?. Describes the patient’s current condition . Usually includes chief complaint . \"One of the most critical skills that occupational therapists must learn is effective documentation.   With that idea in mind,
Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition
presents a systematic approach to a standard form of health care documentation: the SOAP note. The clinical reasoning skills underlying SOAP note documentation can be adapted to fit the written or electronic documentation requirements of nearly any occupational therapy practice setting.   This new
Fourth Edition
has been updated to reflect current information essential to contemporary occupational therapy practice, including the AOTA’s Occupational Therapy Practice Framework: Domain & Process, Third Edition.  
Documentation Manual for Occupational Therapy, Fourth Edition
also includes the COAST method, a specific format for writing occupation-based goals.   Crystal Gateley and Sherry Borcherding use a “how-to” strategy by breaking up the documentation process into a step-by-step sequence. Numerous worksheets are provided to practice each individual skill as well as the entire SOAP note process. In addition, examples from a variety of practice settings are included as a reference. Although this text addresses documentation in occupational therapy practice, the concepts can be generalized across other health care disciplines as well.  New in the Fourth Edition:The chapter focusing on reimbursement, legal, and ethical considerations has been vastly expanded to provide an overview of sources of reimbursement, regulatory guidelines, and legal and ethical issues.A new chapter focusing on electronic documentation has been added to illustrate how the concepts presented in this text can be used in various electronic documentation software products.Faculty will have access to 12 videos that can be used for instructional purposes and documentation practice.This edition includes an expanded Instructor’s Manual with sample quiz questions for several of the chapters, templates and grading rubrics for documentation assignments, and other instructional resources.  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: Writing SOAP Notes, Fourth Edition
presents essential documentation skills that all occupational therapy clinicians, faculty, and students will find critical for assessing, treating, and offering the best evidence available for their clients.  \" \"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 Edition
is 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 assignmentsAs in the previous editions,
Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Edition
focuses 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 Edition
presents 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. \" \"Now updated to its
Fourth Edition, The OTA’s Guide to Documentation: Writing SOAP Notes
contains the step-by-step instruction needed to learn occupational therapy documentation and meet the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Written in an easy-to-read- format, this
Fourth Edition
by Marie J. Morreale and Sherry Borcherding will aid occupational therapy assistants (OTAs) in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice. Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout
The OTA’s Guide to Documentation: Writing SOAP Notes, Fourth Edition
, including a practical method for goal writing (COAST), which is explained thoroughly. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language. Answers to all the worksheets are provided to enable independent study, and a detachable summary sheet can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions.New in the Fourth Edition:Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Third Edition and other updated American Occupational Therapy Association documentsAdditional information on electronic health records and more examples from emerging niches of occupational therapy practiceUpdated information to meet Medicare Part B and other third party payer requirementsAdditional lists of professional language and abbreviationsExtra tips for avoiding common documentation mistakesNew tables, worksheets, and learning activities  Instructors in educational settings can visit www.efacultylounge.com for additional material to be used in the classroom. Updated with new features and information,
The OTA’s Guide to Documentation: Writing SOAP Notes, Fourth Edition
offers both the instruction and multiple opportunities to practice documentation, providing OTAs with the necessary skills to record client care effectively.Bonus Video Content: When you purchase a new copy of 
The OTA’s Guide to Documentation: Writing SOAP Notes, Fourth Edition
, you will receive access to scenario-based videos to practice the documentation process.   \" \"With the current changes in health care, proper documentation of client care is essential in meeting the legal, ethical, and professional standards for reimbursement of services.  Written specifically for occupational therapy assistants,
The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition
contains the step-by-step instruction needed to learn the documentation required for occupational therapy clinical practice and reimbursement. Written in an easy-to-read format, this
Third Edition
by Marie J. Morreale and Sherry Borcherding allows occupational therapy assistants to learn the purpose and standards of documentation throughout all stages of the occupational therapy process and in a variety of practice settings. New features in the Third Edition:·         Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Second Edition  along with other updated American Occupational Therapy Association documents·         Electronic documentation information·         Information on International Classification of Functioning, Disability, and Health language·         Information on narrative notes with examples·         A new chapter on “Billing and Reimbursement” with a focus on funding sources and requirements·         More information and examples for pediatric, school-based, and mental health practice settings·         Information on quality measures·         New worksheets for developing occupational therapy goals·         Additional worksheets on documentation mistakes and basics of documentation·         A new method of goal writing (COAST)·         Lists of professional language This text teaches the SOAP notes format reimbursable by Medicare Part B and other third party payers. Other topics include a review of spelling and grammar, an overview of the initial evaluation process delineating the roles of the occupational therapist and the occupational therapy assistant, tips for clinical reasoning, and guidelines for selecting appropriate interventions.
 
Instructors in educational settings can visit www.efacultylounge.com for additional material to be used in the classroom.
 

The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition
offers both the necessary instruction and multiple opportunities to practice. Templates allow beginning students to practice formatting SOAP notes, and a detachable summary sheet can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Multiple worksheets are provided for practice in developing observation skills, clinical reasoning, documentation skills, and a repertoire of professional language. All worksheets in this
Third Edition
are available online, with answers included to enable independent study. Occupational therapy assistant students and faculty as well as practicing occupational therapy assistants and rehabilitation professionals will appreciate this valuable text. As a bonus:When you purchase a new copy of
The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition
, you will receive access to scenario-based videos to practice the documentation process.\" OR. The pitfalls of Audit!. Tim Rees Professional Lead Occupational Therapist. September 2016. Content. Outline of the audit proposal. Developing the audit tool. Data collection. Findings. What next!.