| Description |
xiii, 248 pages ; 28 cm |
|
regular print |
| Contents |
Introduction to note writing -- Writing in a medical record -- Medical terminology -- Using abbreviations -- The patient/client management format : writing history -- The patient/client management format : writing systems review -- The patient/client management format : documenting tests and measures -- The SOAP note : stating the problem -- The SOAP note : writing subjective (S) -- The SOAP note : writing objective (O) -- Writing evaluation -- Writing the diagnosis -- Writing the prognosis -- Writing expected outcomes (long term goals) -- Writing anticipated goals (short term goals) -- Documenting planned interventions -- Overview of the medical record -- Legal aspects of the medical record -- Reimbursement -- Applications and variations in note writing -- Alternatives : documentation forms and computerized documentation -- The future : documentation using the ICF system |
| Summary |
Twenty-two chapters cover background information on note taking; documenting the examination, the evaluation, and the plan of care; the medical record; and applications of documental skills. Each chapter includes explanatory text and worksheets; answers are included in the back. The fourth edition contains new chapters on writing evaluation, overview and legal aspects of the medical record, reimbursement, and the future - documentation using the WHO's ICF model |
| Notes |
Rev. ed. of: Writing SOAP notes / Ginge Kettenbach. 3rd ed. c2004 |
| Bibliography |
Includes bibliographical references |
| Subject |
Physical therapy -- Documentation -- Problems, exercises, etc.
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Occupational therapy -- Documentation -- Problems, exercises, etc.
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Medical protocols -- Problems, exercises, etc.
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Note-taking -- Problems, exercises, etc.
|
| Genre/Form |
Problems and exercises.
|
| Author |
Kettenbach, Ginge.
Writing SOAP notes
|
| LC no. |
2008030774 |
| ISBN |
9780803618787 paperback alkaline paper |
|
0803618786 paperback alkaline paper |
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