�(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

Slack Incorporated Web Site, January, 2002

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.

Chapter 1: Documenting the Treatment Process in Occupational Therapy
Chapter 2: The Medical 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: Treatment 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
Bibliography
Appendix: Suggestions for Completing the Worksheets
Note to the Reader
Index