Don't Drop
the SOAP!
the SOAP!
The client's progress and potential are put in this section of the SOAP format of documentation.
What is Assessment?
The summary of a client's ability between initial evaluation & discontinuation of service.
What is a discharge report/summary?
Surf's up when writing goals using this method.
What is COAST?
COTA
Certified Occupational Therapy Assistant
Occupational therapy documentation should always record practitioners activity in these areas.
What are screening, evaluation, interventions and outcomes?
This formal plan is documented when client moves from one setting to another within a service delivery system?
What is a transition plan?
AMA
Against medical advice
These are 3 types of intervention documentations.
What are the intervention plan, daily note, progress report?
An example of this section of SOAP might include: continue 1 hour daily sessions for 1week.
What is Plan?
A summary of the intervention process and progress toward goals is in this type of documentation.
What is a progress report?
NPO
Nothing by mouth
Documentation should always be done in accordance with these entities.
What are the payer, facility, state and federal guidelines?
The statement: Client seen for 1 hour in clinic kitchen for skilled instruction in compensatory techniques for cooking- goes under this section of SOAP.
What is objective?
This document will contain some background information about the client, and potential challenges prior to formal services beginning.
What is a History and Screening
An OT that violates the Occupational Therapy Code of Ethics would be censured by this body.
What is AOTA?
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Approximately
Precautions & contraindications are indicated in this type of documentation.
What is all types of documentations from a screening to a discharge report.
Therapy goals are written in this section of SOAP.
What is Plan? * Where else could they possibly be written?
Attendance & participation may be recorded in this type of service contact document.
What is a flow sheet?
This legislation protects your information while in school.
What is FERPA?
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to and from
These are three principles that guide contemporary occupational therapy practice and should be reflected in documentation.
What are client-centered practice, occupation-based practice and evidence-based practice?