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…mehr
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.
Crystal A. Gateley, PhD, OTR/L is Associate Chair and Associate Teaching Professor at University of Missouri in Columbia, where she has taught since 2009. She teaches a variety of courses across the curriculum including Foundations & Theory in OT, Clinical Pathophysiology, Human Development & Occupations I and II, Level I Fieldwork, and Clinical Reasoning & Documentation. Crystal graduated Summa Cum Laude from University of Missouri with a BHS in Occupational Therapy and went on to complete a master's and doctorate in Educational Leadership and Policy Analysis (ELPA), also from University of Missouri. Crystal has worked in a variety of occupational therapy practice settings, including acute care, inpatient and outpatient rehabilitation, skilled nursing, home health, outpatient pediatrics, public schools, and sheltered workshops. Besides teaching, Crystal enjoys attending her daughters' extracurricular events, particularly Southern Boone Lady Eagles soccer and basketball, and frequently volunteers her time to support school and community organizations. She also loves camping, fishing, canoeing, and boating with family and friends. Sherry Borcherding, MA, OTR/L is retired from the faculty of University of Missouri, where she taught for 15 years. During the time she was on faculty, she taught disability awareness; complementary therapy; clinical ethics; frames of reference; psychopathology; loss and disability; long-term care; wellness; and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. Two of her courses were designated as campus writing courses and one was credentialed for computer and information proficiency. As a part of the fieldwork and documentation courses, she filmed simulated occupational therapy interventions for student use in class. Twelve of those "movies" are available on www.efacultylounge.com with this edition of the book. Sherry graduated with honors from Texas Woman's University, Denton, Texas 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, Nashville, Tennessee. 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, Kilgore, Texas; Director of Occupational Therapy at Mid-Missouri Mental Health Center, Columbia; and Director of Rehabilitation Services at Transitional Housing Agency, Columbia, Missouri. She has also planned, designed and directed occupational therapy programs at Capital Regional Medical Center, Jefferson City, Missouri and at Charter Behavioral Health Center, Columbia, Missouri. Sherry is a lifelong learner. Since her retirement, she has further expanded her private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy at the techniques level through Upledger Institute, Palm Beach Gardens, Florida and is attuned as a Reiki master. For leisure, Sherry enjoys music, English country dance, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past several years. She volunteers with the Community Emergency Response Team doing logistics.
Inhaltsangabe
Dedication Acknowledgments About the Authors Chapter 1 Documenting the Occupational Therapy Process Chapter 2 The Health Record Chapter 3 Reimbursement, Legal, and Ethical Considerations Chapter 4 General Guidelines for Documentation Chapter 5 Writing Occupation-Based Problem Statements Chapter 6 Writing Measurable Occupation-Based Goals and Objectives Chapter 7 Writing the S-Subjective Chapter 8 Writing the O-Objective Chapter 9 Writing the A-Assessment Chapter 10 Writing the P-Plan Chapter 11 Making Good Notes Even Better Chapter 12 Intervention Planning Chapter 13 Documenting Different Stages of Service Delivery Chapter 14 Documentation in Different Practice Settings Chapter 15 Electronic Documentation Chapter 16 Examples of Different Kinds of Notes Appendix: Suggestions for Completing the Worksheets Index
Dedication Acknowledgments About the Authors Chapter 1 Documenting the Occupational Therapy Process Chapter 2 The Health Record Chapter 3 Reimbursement, Legal, and Ethical Considerations Chapter 4 General Guidelines for Documentation Chapter 5 Writing Occupation-Based Problem Statements Chapter 6 Writing Measurable Occupation-Based Goals and Objectives Chapter 7 Writing the S-Subjective Chapter 8 Writing the O-Objective Chapter 9 Writing the A-Assessment Chapter 10 Writing the P-Plan Chapter 11 Making Good Notes Even Better Chapter 12 Intervention Planning Chapter 13 Documenting Different Stages of Service Delivery Chapter 14 Documentation in Different Practice Settings Chapter 15 Electronic Documentation Chapter 16 Examples of Different Kinds of Notes Appendix: Suggestions for Completing the Worksheets Index
Es gelten unsere Allgemeinen Geschäftsbedingungen: www.buecher.de/agb
Impressum
www.buecher.de ist ein Shop der buecher.de GmbH & Co. KG Bürgermeister-Wegele-Str. 12, 86167 Augsburg Amtsgericht Augsburg HRA 13309