even though the course says it is geared toward home health ot and pt practitioners, i have found this information to be completely applicable to other settings. this is post is an example of the content that is in the learning lab membership – helping you to have the resources you need to feel confident and successful as an ot practitioner and student! it is our job to paint a picture of what is going on with our patient, why they are or aren’t progressing and lay out a plan for progressing the goals, adapting the goals or shifting direction in care. s: the patient states that she has not been able to use her wheelchair around her home due to her “hands hurting” and “i am not able to get a good grip.”
i wanted to get otps thinking about how documenting can paint a picture of the pt and decrease denials. another one that is a 2 part series about documentation is “series: medicare updates” just listened to this again for ideas to improve my ot home health documentation. i teach this skill set in an ota program and i am constantly reminding my students that the language in our documentation is what justifies the billing codes that are selected. kornetti and krafft provide these seminars on documentation/regulation/etc to all disciplines ???? please share and get the word out – we all need help in documentation!
depending on the setting you are in and the electronic medical records system they are using for documentation, the format of your soap daily treatment note may be different—but the general execution should remain the same. most times, this is because they are under a lot of pressure for productivity and they don’t know the true weight of what they are writing. if you are an ot business owner, your documentation matters even more! #defensivedocumentation in daily notes is imperative as a form of passive advocacy for the occupational therapy profession. the subjective section of a daily treatment soap is qualitative data from your patient/client.
this is the objective and quantifiable data that you must include for insurance and payor justification as well as to provide evidence that your skilled intervention is necessary for the betterment and healing of your patient. again, you are note comparing past and present performance in your the objective portion of your daily treatment note! this comparison should placed in the “assessment” section if there is something of notable mention so that the progressive change can be noted easily soap for occupational therapy progress notes. remember the assessment section is the place where a clinician interprets and compares data using a skilled lens. the assessment section of a daily treatment soap is the combination and interpretation of the client-driven quantitative (subjective) and qualitative (objective) data from your patient/client. this section is where you create the medical and social narrative of your client!
in this post, i will also be sharing basic tips, an occupational therapy soap note example and template, and include key phrases for billing and this resource is for school-based occupational therapy daily note-taking! it is in a word format which makes it customizable. – a physical and occupational therapist providing you with evidence-based treatments and examples of documentation to show your skill., school-based occupational therapy daily notes template, ot documentation cheat sheet, ot documentation cheat sheet, soap notes occupational therapy template, soap notes occupational therapy pdf.
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