Writing Soap Notes: with Patient/Client Management Formats Book

Ginge Kettenbach's revision teaches students and new practitioners the basic skills needed to write two different styles of documentation: SOAP (Subjective/Objective/Assessment/Plan) notes and Patient/Client Management forms. This updated edition includes even more exercises to help students learn how to write clear, concise, and correct patient care notes. Worksheets at the end of each note section encourage clinical decision making on the information they have just learned. Rationales are given for all decisions.

WHAT'S NEW:

• New chapters offer background and instruction on the emerging Patient/Client Management format so students will know how to write patient care notes as alternative formats develop
• Updated to incorporate the uniform terminology of the APTA's Guide to Physical Therapist Practice into relevant, usable formats consistent with today's emphasis on evidence-based practice
• Examples, especially on the "A" part of the notes, refer to the diagnostic categories in the Guide and strengthen students' ability to communicate more effectively with other members of a patient/client's health-care team
• Examples include more home care and outpatient cases in line with the trend to shorten or eliminate inpatient treatments
• Additional exercises and examples help students sharpen the decision-making and writing skills needed to prepare good medical reports

• Coverage of Medicare forms and computerized documentation
• Basic note-writing rules, including the POMR method, are reviewed
• Samples provided of both correct and incorrect note writing

The book contains no figures.