Documentation Manual for Occupational Therapy: Writing SOAP Notes

274 Pages·2017·129.6 MB·English

by  Crystal A. Gateley, Sherry Borcherding

Documentation Manual
for Occupational Therapy
Writing SOAP Notes
FOURTH EDITION

Documentation Manual
for Occupational Therapy
Writing SOAP Notes
FOURTH EDITION
A. OTR/L
CRYSTAL GATELEY, PHD,
&
AssociATE CHAIR AssociATE TEACHING PROFESSOR
DEPARTMENT OF OCCUPATIONAL THERAPY
UNIVERSITY OF MISSOURI- SCHOOL OF HEALTH PROFESSIONS
COLUMBIA, MISSOURI
MA, OTR/l
SHERRY BORCHERDING,
CLINICAL ASSOCIATE PROFESSOR, RETIRED
UNIVERSITY OF MISSOURI
COLUMBIA, MISSOURI
SLACK
INCORPORATED
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Copyright@ 2017 by SLACK Incorporated
Instructors: Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition Instructor's Manual is also available
from SLACK Incorporated. Don't miss this important companion to Documentation Manual for Occupational Therapy: Writing SOAP
Notes, Fourth Edition. To obtain the Instructor's Manual, please visit http:/fwww.efacultylounge.com
Dr. Crystal A. Gateley and Sherry Borcherding have no financial or proprietary interest in the materials presented herein.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means,
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embodied in critical articles and reviews.
The procedures and practices described in this publication should be implemented in a manner consistent with the professional standards
set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information
presented and to correctly relate generally accepted practices. The authors, editors, and publisher cannot accept responsibility for errors
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Library of Congress Cataloging-in-Publication Data
Names: Gateley, Crystal A.,-author. I Borcherding, Sherry, author.
Title: Documentation manual for occupational therapy : writing SOAP notes I
Crystal A. Gateley, Sherry Borcherding.
I I
Description: Fourth edition. Thorofare, NJ: SLACK Incorporated, [2017]
Preceded by Documentation manual for occupational therapy : writing SOAP
notes I Crystal A. Gateley, Sherry Borcherding. 3rd ed. c2012.1 Includes
bibliographical references and index.
I I
Identifiers: LCCN 2016026325 (ebook) ISBN 9781630912321 {epub) ISBN
9781630912338 (web)
I I I
Subjects: MESH: Forms and Records Control Occupational Therapy--methods
I I I
Patient Care Planning Medical Records Writing Handbooks
I I I
Classification: LCC RM735.4 (print) LCC RM735.4 {ebook) NLM WB 39 DDC
615.8l515--dc23
LC record available at https://lccn.loc.gov/2016025712
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DEDICATION
This book is dedicated to all of my past, current, and future OT students who make teaching a wonderful and reward
ing experience. It is my hope that this book will serve you in your endeavors to provide compassionate care to your clients
and to communicate the benefit of the occupational therapy profession.
Crystal A. Gateley, PhD, OTR/L
This book is dedicated to the occupational therapy students, faculty, and fieldwork instructors who have taught me
so much about documentation, and to my grandson, Jan, who carries on the family tradition in occupational therapy.
Sherry Borcherding, MA, OTR/L

CONTENTS
Dedication .............................................................................................v
Acknowledgments ...................................................................................... ix
About the Authors ...................................................................................... xi
Chapter 1 Documenting the Occupational Therapy Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Chapter2 The Health Record. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Chapter 3 Reimbursement, Legal, and Ethical Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Chapter4 General Guidelines for Documentation ...................................................... 29
Chapter 5 Writing Occupation-Based Problem Statements .............................................. 45
Chapter6 Writing Measurable Occupation-Based Goals and Objectives. .................................. 57
Chapter 7 Writing the "S" -Subjective . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Chapter 8 Writing the "0"- Objective .................................................................8 1
Chapter9 Writing the "A" -Assessment ............................................................... 99
Chapter 10 Writing the "P"- Plan .....................................................................1 15
Chapter 11 Making Good Notes Even Better. .......................................................... 123
Chapter 12 Intervention Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Chapter 13 Documenting Different Stages of Service Delivery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 14 Documentation in Different Practice Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Chapter 15 Electronic Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
Chapter 16 Examples of Different Kinds ofNotes .......................................................2 11
Appendix: Suggestions for Completing the Worksheets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235
Instructors: Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition Instructor's Manual is also available
from SLACK Incorporated. Don't miss this important companion to Documentation Manual for Occupational Therapy: Writing SOAP
Notes, Fourth Edition. To obtain the Instructor's Manual, please visit http://www.efacultylounge.com