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Copy of Writing SOAP notes and Creating Measurable Occupational Based Goals
Transcript of Copy of Writing SOAP notes and Creating Measurable Occupational Based Goals
Describe the four sections of a SOAP note
Define the five sections of writing a measurable and occupation-based goal
Identify an OT problem and write short term and long term goals after viewing treatment session video
Write a SOAP note based on video of OT treatment session
A permanent health record
Required for reimbursement
It is a legal document
Need to follow ethical and legal standards Documentation of Occupational Therapy SUBJECTIVE
PLAN WRITING A SOAP NOTE C: CLIENT
A: ASSIST LEVEL
S: SPECIFIC CONDITION
T: TIMELINE GOAL WRITING: COAST METHOD Please view this video and then:
1. Write an OT problem.
2. Write an OT LTC
3. Write 4 OT STGs ASSUMPTIONS Someone else will need to read and understand the documentation
The entry will be scrutinized by third party payers
The client has the right to read the record GENERAL GUIDELINES FOR OCCUPATIONAL THERAPY DOCUMENTATION Use waterproof, non erasable black ink
Never use correction fluid to make corrections
Always write legibly BE SURE TO: Have all required data present
Sign and date every entry YOU ALSO NEED TO: Identify the client on every page
Document in a timely manner
Use appropriate terminology
Use appropriate abbreviations
Emphasize skilled intervention
Document progress and intentions DO NOT FORGET TO:
Focus on the client and NOT yourself
Adhere to legal and ethical guidelines
Subjective Write something the client says about their condition or treatment session EXAMPLE:
S: Pt. stated "this session was a little to difficult for me, I am very tired." Objective Statements that include:
Length and purpose of session
Summary of what you have observed
Be professional and concise
Client's response to treatment
Be specific on assist levels and avoid judging the client Sample Objective Entry Pt. seen bedside for a 30 minute OT session.
VSR: Pre -Activity BP: 120/80 HR: 80 bpm
Post Activity BP: 130/86 HR: 88 bpm
Grooming- Pt. stood at sink for 3 minutes to comb hair and brush teeth with close supervision with appropriate VSR.
Functional Transfers: Pt. able to go from bed to commode with a stand pivot transfer with close supervision. Assessment Go sentence to sentence through information presented in the subjective and objective sections
Decide what it means for the client's ability to engage in meaningful occupation
Note the problems, progress and potential for rehabilitation
Include what the client would benefit from and what they need in a skilled OT situation Wendy Wachter-Schutz, MS, OTR/L Modified for use with Howard OT students, April 2013
Jessica Alden, OTD
Lynda Hill, OTD Sample Assessment Entry Patient tolerated OT bedside session well with appropriate VSR after each activity with some complains of fatigue throughout session. Patient is now at a close supervision level for basic grooming activities and functional transfers to the commode because of complaints of fatigue, impairments in balance, and fear of falling. Patient would benefit from continued OT to reach goals set in initial evaluation of complete independence in all areas of ADL and IADL by addressing deficits in standing balance and endurance and by addressing fear of falling Plan Specify the frequency and duration of OT services
Describe the purpose of future OT sessions Sample Plan Entry Continue OT services 3 to 4 times a week until discharge from hospital to reach goals of complete independence in all ADL and IADL as stated in initial evaluation CLIENT CLIENT WILL PERFORM......... OCCUPATION WHAT OCCUPATION? ASSISTANCE LEVEL WITH WHAT LEVEL OF ASSISTANCE/INDEPENDENCE? SPECIFIC CONDITION UNDER WHAT CONDITION? TIMELINE BY WHEN? SAMPLE COAST METHOD GOALS Client will prepare a three step meal in the rehabilitation kitchen with modified independence from wheelchair level within two weeks.
Within three treatment sessions, Mr. S will compete toileting using raised toilet seat with minimal assistance for balance during clothing adjustment. WRITING SOAP NOTES AND CREATING MEASURABLE OCCUPATIONAL BASED GOALS A JOURNEY for Occupational Therapy Students REFERENCES Gately, C.A., & Borcerding, S. (2012). Documentation manual for occupational therapy. Writing SOAP notes. (3rd ed.). Thorofare, NJ: Slack Incorporated.
Sames, K. ( 2010). Documenting occupational therapy practice. (2nd ed.). Upper Saddle River, NJ: Person.
Vanderbilt University (n.d.). Center for Teaching. Retrieved from: http://cft.vanderbilt.edu/teaching-guides/teaching-activities/lecturing/