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Soap Notes
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Download or read book SOAP Notes written by Jeremiah Fleenor and published by Mdpocket. This book was released on 2007-03 with total page 0 pages. Available in PDF, EPUB and Kindle. Book excerpt: A SOAP note records an encounter with a patient. The components are Subjective (what the patient tells the recorder), Objective (what the recorder observes), Assessment (recorder's summation), Plan (recorder's actions, based on the assessment).
Book Synopsis Writing Patient/Client Notes by : Ginge Kettenbach
Download or read book Writing Patient/Client Notes written by Ginge Kettenbach and published by F.A. Davis. This book was released on 2016-05-11 with total page 295 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop all of the skills you need to write clear, concise, and defensible patient/client care notes using a variety of tools, including SOAP notes. This is the ideal resource for any health care professional needing to learn or improve their skills—with 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 Patient/Client Management and WHO’s ICF model.
Book Synopsis Documentation Manual for Writing SOAP Notes in Occupational Therapy by : Sherry Borcherding
Download or read book Documentation Manual for Writing SOAP Notes in Occupational Therapy written by Sherry Borcherding and published by Slack Incorporated. This book was released on 2005 with total page 236 pages. Available in PDF, EPUB and Kindle. Book excerpt: Manual focusing on documenting the occupational therapy process. Each skill is broken down into small steps and taught individually. Includes a template for writing problems, goals, and each section of the SOAP note. Also includes practice worksheets and detachable checklist and summary.
Book Synopsis SOAP for the Rotations by : Peter S. Uzelac
Download or read book SOAP for the Rotations written by Peter S. Uzelac and published by Lippincott Williams & Wilkins. This book was released on 2019-07-11 with total page 512 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ideal for medical students, PAs and NPs, this pocket-sized quick reference helps students hone the clinical reasoning and documentation skills needed for effective practice in internal medicine, pediatrics, OB/GYN, surgery, emergency medicine, and psychiatry. This updated edition offers step-by-step guidance on how to properly document patient care as it addresses the most common clinical problems encountered on the wards and clinics. Emphasizing the patient’s clinical problem, not the diagnosis, the book’s at-a-glance, two-page layout uses the familiar SOAP note format.
Book Synopsis SOAP for Family Medicine by : Daniel Maldonado
Download or read book SOAP for Family Medicine written by Daniel Maldonado and published by Lippincott Williams & Wilkins. This book was released on 2018-08-14 with total page 289 pages. Available in PDF, EPUB and Kindle. Book excerpt: Offering step-by-step guidance on how to properly document patient care, this updated Second Edition presents 90 of the most common clinical problems encountered on the wards and clinics in an easy-to-read, two-page layout using the familiar "SOAP" note format. Emphasizing the patient’s clinical problem, not the diagnosis, this pocket-sized quick reference teaches both clinical reasoning and documentation skills and is ideal for use by medical students, Pas, and NPs during the Family Medicine rotation.
Book Synopsis The OTA's Guide to Writing SOAP Notes by : Sherry Borcherding
Download or read book The OTA's Guide to Writing SOAP Notes written by Sherry Borcherding and published by SLACK Incorporated. This book was released on 2007 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: Written specifically for occupational therapy assistants, The OTA's Guide to Writing SOAP Notes, Second Edition is updated to include new features and information. This valuable text contains the step-by-step instruction needed to learn the documentation required for reimbursement in occupational therapy. With the current changes in healthcare, proper documentation of client care is essential to meeting legal and ethical standards for reimbursement of services. Written in an easy-to-read format, this new edition by Sherry Borcherding and Marie J. Morreale will continue to aid occupational therapy assistants in learning to write SOAP notes that will be reimbursable under Medicare Part B and managed care for different areas of clinical practice. New Features in the Second Edition: - Incorporated throughout the text is the Occupational Therapy Practice Framework, along with updated AOTA documents - More examples of pediatrics, hand therapy, and mental health - Updated and additional worksheets - Review of grammar/documentation mistakes - Worksheets for deciphering physician orders, as well as expanded worksheets for medical abbreviations - Updated information on billing codes, HIPAA, management of health information, medical records, and electronic documentation - Expanded information on the OT process for the OTA to fully understand documentation and the OTA's role in all stages of treatment, including referral, evaluation, intervention plan, and discharge - Documentation of physical agent modalities With reorganized and shorter chapters, The OTA's Guide to Writing SOAP Notes, Second Edition is the essential text to providing instruction in writing SOAP notes specifically aimed at the OTA practitioner and student. This exceptional edition offers both the necessary instruction and multiple opportunities to practice, as skills are built on each other in a logical manner. Templates are provided for beginning students to use in formatting SOAP notes, and the task of documentation is broken down into small units to make learning easier. A detachable summary sheet is included that can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. "Answers" are provided for all worksheets so that the text can be used for independent study if desired. Updated information, expanded discussions, and reorganized learning tools make The OTA's Guide to Writing SOAP Notes, Second Edition a must-have for all occupational therapy assistant students! This text is the essential resource needed to master professional documentation skills in today's healthcare environment.
Book Synopsis SOAP for Obstetrics and Gynecology by : Peter S. Uzelac
Download or read book SOAP for Obstetrics and Gynecology written by Peter S. Uzelac and published by Lippincott Williams & Wilkins. This book was released on 2005 with total page 174 pages. Available in PDF, EPUB and Kindle. Book excerpt: SOAP for Obstetrics and Gynecology features over 60 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. The SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar "SOAP" note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem, not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a "must-have" to keep in their white coat pockets for wards and clinics.
Book Synopsis SOAP for Pediatrics by : Michael A. Polisky
Download or read book SOAP for Pediatrics written by Michael A. Polisky and published by Lippincott Williams & Wilkins. This book was released on 2005 with total page 196 pages. Available in PDF, EPUB and Kindle. Book excerpt: SOAP for Pediatrics features over 70 clinical problems with each case presented in an easy to read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach the students important steps in clinical care. Blackwell's new SOAP series is a unique resource that also provides a step-by-step guide to learning how to properly document patient care. Covering the problems most commonly encountered on the wards, the text uses the familiar "SOAP" note format to record important clinical information and guide patient care. SOAP format puts the emphasis back on the patient's clinical problem not the diagnosis. This series is a practical learning tool for proper clinical care, improving communication between physicians, and accurate documentation. The books not only teach students what to do, but also help them understand why. Students will find these books a "must have" to keep in their white coat pockets for wards and clinics.
Download or read book SOAP for Cardiology written by Eric Awtry and published by Lippincott Williams & Wilkins. This book was released on 2006-04-01 with total page 160 pages. Available in PDF, EPUB and Kindle. Book excerpt: SOAP for Cardiology features over 50 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach students important steps in clinical care. The SOAP series offers step-by-step guidance in documenting patient care, using the familiar "SOAP" note format to record important clinical information and guide patient care. The SOAP format makes this book a unique practical learning tool for clinical care, communication between physicians, and accurate documentation—a "must-have" for students to keep in their white coat pockets for wards and clinics.
Book Synopsis Writing SOAP Notes by : Ginge Kettenbach
Download or read book Writing SOAP Notes written by Ginge Kettenbach and published by F A Davis Company. This book was released on 2003 with total page 215 pages. Available in PDF, EPUB and Kindle. Book excerpt: Ginge Kettenbach's workbook leads you through the process of learning two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and the Patient/Client Management format. This updated 3rd edition includes hands-on exercises and examples to help you sharpen the writing skills that you will need to prepare clear, concise, and accurate medical documentation. Worksheets at the end of each note section further strengthen your writing skills on the information you have just learned. Explanations of documentation that are consistent with the APTA's Guide to Physical Therapist Practice are given for all decisions. Book jacket.
Book Synopsis SOAP for Neurology by : Frank P. Lin
Download or read book SOAP for Neurology written by Frank P. Lin and published by Lippincott Williams & Wilkins. This book was released on 2006 with total page 198 pages. Available in PDF, EPUB and Kindle. Book excerpt: SOAP for Neurology features 60 clinical problems with each case presented in an easy-to-read 2-page layout. Each step presents information on how that case would likely be handled. Questions under each category teach students important steps in clinical care. The SOAP series also offers step-by-step guidance in documenting patient care, using the familiar "SOAP" note format to record important clinical information and guide patient care. The SOAP format makes this book a unique practical learning tool for clinical care, communication between physicians, and accurate documentation—a "must-have" for students to keep in their white coat pockets for wards and clinics.
Book Synopsis Guide to Clinical Documentation by : Debra Sullivan
Download or read book Guide to Clinical Documentation written by Debra Sullivan and published by F.A. Davis. This book was released on 2011-12-22 with total page 301 pages. Available in PDF, EPUB and Kindle. Book excerpt: Develop the skills you need to effectively and efficiently document patient care for children and adults in clinical and hospital settings. This handy guide uses sample notes, writing exercises, and EMR activities to make each concept crystal clear, including how to document history and physical exams and write SOAP notes and prescriptions.
Download or read book NP Notes written by ruth McCaffrey and published by F.A. Davis. This book was released on 2017-10-23 with total page 285 pages. Available in PDF, EPUB and Kindle. Book excerpt: Put this handy guide to work in class, in clinical, and in practice. From screening and assessment tools and differential diagnosis through the most commonly ordered drugs and billing and coding, this volume in the Davis Notes Series presents the information you need every day in a pocket-sized resource.
Book Synopsis Documentation Basics by : Mia Erickson
Download or read book Documentation Basics written by Mia Erickson and published by SLACK Incorporated. This book was released on 2012 with total page 176 pages. Available in PDF, EPUB and Kindle. Book excerpt: Complete and accurate documentation is one of the most important skills for a physical therapist assistant to develop and use effectively. The new Second Edition of Documentation Basics: A Guide for the Physical Therapist Assistant continues the path of teaching the student and clinician documentation from A to Z.
Book Synopsis Writing Skills for Veterinarians by : Ryane E. Englar
Download or read book Writing Skills for Veterinarians written by Ryane E. Englar and published by 5m Books Ltd. This book was released on 2019-02-05 with total page 268 pages. Available in PDF, EPUB and Kindle. Book excerpt: Communicating ideas in veterinary medicine is a fundamental part of continuing veterinary research and building a career as a clinician. The purpose of this book is to help increasing efficiency and effectiveness in writing professional documents, e.g. writing a concise yet thorough discharge statement to avoid repeated client call-backs to clarify medical recommendations. The book also aims at improving the reader’s confidence in writing skills through guided and well-thought out “homework” or practice exercises. Useful for both veterinary students and practising vets, Writing Skills for Veterinarians addresses how to develop and hone veterinary medical and scientific writing techniques. The basics of veterinary writing and why it matters are covered before concentrating on specific written models expected of vets – creating medical documents, client and colleague communications, report writing, journal articles and research papers and presentations. At the end of the book is a resource-bank of additional exercises relating to each type of document. 5m Books
Book Synopsis Charting Spiritual Care by : Simon Peng-Keller
Download or read book Charting Spiritual Care written by Simon Peng-Keller and published by Springer Nature. This book was released on 2020-08-10 with total page 244 pages. Available in PDF, EPUB and Kindle. Book excerpt: This open access volume is the first academic book on the controversial issue of including spiritual care in integrated electronic medical records (EMR). Based on an international study group comprising researchers from Europe (The Netherlands, Belgium and Switzerland), the United States, Canada, and Australia, this edited collection provides an overview of different charting practices and experiences in various countries and healthcare contexts. Encompassing case studies and analyses of theological, ethical, legal, healthcare policy, and practical issues, the volume is a groundbreaking reference for future discussion, research, and strategic planning for inter- or multi-faith healthcare chaplains and other spiritual care providers involved in the new field of documenting spiritual care in EMR. Topics explored among the chapters include: Spiritual Care Charting/Documenting/Recording/Assessment Charting Spiritual Care: Psychiatric and Psychotherapeutic Aspects Palliative Chaplain Spiritual Assessment Progress Notes Charting Spiritual Care: Ethical Perspectives Charting Spiritual Care in Digital Health: Analyses and Perspectives Charting Spiritual Care: The Emerging Role of Chaplaincy Records in Global Health Care is an essential resource for researchers in interprofessional spiritual care and healthcare chaplaincy, healthcare chaplains and other spiritual caregivers (nurses, physicians, psychologists, etc.), practical theologians and health ethicists, and church and denominational representatives.
Book Synopsis Seidel's Guide to Physical Examination - E-Book by : Jane W. Ball
Download or read book Seidel's Guide to Physical Examination - E-Book written by Jane W. Ball and published by Elsevier Health Sciences. This book was released on 2017-12-21 with total page 725 pages. Available in PDF, EPUB and Kindle. Book excerpt: NEW! Emphasis on clinical reasoning provides insights and clinical expertise to help you develop clinical judgment skills. NEW! Enhanced emphasis on patient safety and healthcare quality, particularly as it relates to sports participation. NEW! Content on documentation has been updated with a stronger focus on electronic charting (EHR/EMR). NEW! Enhanced social inclusiveness and patient-centeredness incorporates LGBTQ patients and providers, with special a emphasis on cultural competency, history-taking, and special considerations for examination of the breasts, female and male genitalia, reproductive health, thyroid, and anus/rectum/prostate. NEW! Telemedicine, virtual consults, and video interpreters content added to the Growth, Measurement, and Nutrition chapter. NEW! Improved readability with a clear, straightforward, and easy-to-understand writing style. NEW! Updated drawing, and photographs enhance visual appeal and clarify anatomical content and exam techniques.
