This is the format that we use and it may help you organize your thoughts. We do it this way as insurance and Medical assistance can find information quickly. Kim
S: Any information given or received; what client/parent said; home program information/hand outs given; any medical or school changes. O: (Always start this section with this sentence) 45 min. skilled OT tx to address strength/dexterity/ADLs. (I put all the treatment areas addressed in this session) (Then I start with the area addressed and what was done and at what independence level) example: STRENGTH: reach 1# weight all planes and CLMX with verbal cues DEXTERITY: in palm manipulation of 1"-2" size objects with surface support. ADLs: 1/2" buttons on worn shirt with verbal cue and mod. assist. A: (What you think or impressions or need for changes) example: ADL progressed from shirt on table to worn shirt P: Increase strength to 2# weights in clinic and 1# in home program. Ct. to practice dexerity exercise at home. Cont. POC. OTR/L ----- Original Message ----- From: "pat" <[EMAIL PROTECTED]> To: <[email protected]> Sent: Friday, July 14, 2006 8:58 AM Subject: Re: [OTlist] Some help. >I may be misunderstanding the question, but I am thinking that Emma is asking > for help with SOAP notes as they relate to her dyslexia, not what they are and > how to do them in general. Am I on the right track Emma? > > Pat Ellison > > At 09:24 PM 7/13/2006, you wrote: >>Hello Emma >>First of all - What setting do you work in? Are you required to use the SOAP >>format for your chart notes? >> >>We use a similar but simpler format DARP >>Data - eliminates the need to separate 'subjective' and 'objective'. I find >>this helpful. Using SOAP I was always realising that I had left out >>something the client had told me after I was into my own observations. Of >>course it is necessary to use phrases like 'Mr. B. stated' to clarify where >>the information came from or use quotation marks. Also it is easier to use >>when data comes from several different sources. (Are the daughter's >>contributions S or O?) >>Actions - what you did. This allows you to record what you did 'on the spot' >>rather than writing a plan and developing another note to record stuff >>already done. >>Response - from the client. Quotes are good here. What you want to record is >>whether your action was acceptable to the client and what difference, if >>any, it made. >>Plan - what you are going to do next to fulfill the treatment plan you >>developed after your first assessment. >>If your note is to record a brief contact, one or two episodes, be sure to >>state an occupational performance goal in your plan. >> >>Whichever format you use - I find it helpful to jot down my plan, preferably >>before I leave the client, so I have a written record of what I said I was >>going to do. Then as I begin to write the chart note my plan cues me to what >>happened and why I had decided to do that rather than trying to keep the >>plan in my head while I write all the rest down. Hope this helps. >>Joan Riches >> >> >> > -----Original Message----- >> > From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf >>Of >> > Emma Cole >> > Sent: Sunday, July 09, 2006 9:25 AM >> > To: [email protected] >> > Subject: [OTlist] Some help. >> > >> > Hi, >> > I am a OT in uk and have difficulty with my note writing due to my >>dyslexia. >> > I was wondering if anybody have information on SOAP notes and information >>on >> > writing them as it is getting me down at work. >> > Many thanks >> > >> > emma >> > >> > >> > >> > -- >> > Unsubscribe? >> > [EMAIL PROTECTED] >> > >> > Change options? >> > www.otnow.com/mailman/options/otlist_otnow.com >> > >> > Archive? >> > www.mail-archive.com/[email protected] >> > >> > Help? >> > [EMAIL PROTECTED] >> > >> > -- >> > No virus found in this incoming message. >> > Checked by AVG Free Edition. >> > Version: 7.1.394 / Virus Database: 268.9.10/383 - Release Date: 7/7/2006 >> > >> >>-- >>No virus found in this outgoing message. >>Checked by AVG Free Edition. >>Version: 7.1.394 / Virus Database: 268.10.0/388 - Release Date: 7/13/2006 >> >> >> >>-- >>Unsubscribe? >> [EMAIL PROTECTED] >> >>Change options? >> www.otnow.com/mailman/options/otlist_otnow.com >> >>Archive? >> www.mail-archive.com/[email protected] >> >>Help? >> [EMAIL PROTECTED] > > > > -- > Unsubscribe? > [EMAIL PROTECTED] > > Change options? > www.otnow.com/mailman/options/otlist_otnow.com > > Archive? > www.mail-archive.com/[email protected] > > Help? > [EMAIL PROTECTED] -- Unsubscribe? [EMAIL PROTECTED] Change options? www.otnow.com/mailman/options/otlist_otnow.com Archive? www.mail-archive.com/[email protected] Help? [EMAIL PROTECTED]
