Instructor s Manual CRYSTAL A. GATELEY, MA, OTR/L SHERRY BORCHERDING, MA, OTR/L CLINICAL ASSISTANT PROFESSOR UNIVERSITY OF MISSOURI COLUMBIA, MISSOURI

Instructor s Manual CRYSTAL A. GATELEY, MA, OTR/L CLINICAL ASSISTANT PROFESSOR UNIVERSITY OF MISSOURI COLUMBIA, MISSOURI SHERRY BORCHERDING, MA, OTR/L CLINICAL ASSOCIATE PROFESSOR, RETIRED UNIVERSITY OF MISSOURI COLUMBIA, MISSOURI

Copyright 2012 by SLACK Incorporated All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission from the publisher, except for brief quotations embodied in critical articles and reviews. The procedures and practices described in this book should be implemented in a manner consistent with the professional standards set for the circumstances that apply in each specific situation. Every effort has been made to confirm the accuracy of the information presented and to correctly relate generally accepted practices. The authors, editor, and publisher cannot accept responsibility for errors or exclusions or for the outcome of the material presented herein. There is no expressed or implied warranty of this book or information imparted by it. Any review or mention of specific companies or products is not intended as an endorsement by the author or publisher. SLACK Incorporated uses a review process to evaluate submitted material. Prior to publication, educators or clinicians provide important feedback on the content that we publish. We welcome feedback on this work. Published by: SLACK Incorporated 6900 Grove Road Thorofare, NJ 08086 USA Telephone: 856-848-1000 Fax: 856-853-5991 www.slackbooks.com Contact SLACK Incorporated for more information about other books in this field or about the availability of our books from distributors outside the United States.

Instructor s Manual 3 INTRODUCTION The material contained in this instructor s manual is intended to provide the instructor with ideas and additional resources for use in conjunction with Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Edition. Like the textbook itself, the material presented in this instructor s manual has been developed for use in a course on clinical documentation. The textbook and these supplemental materials may also be useful in Level I Fieldwork and other courses in your curriculum. The instructional materials presented here may be edited or adapted according to the needs of the individual course, instructor, and occupational therapy program. WORKSHEETS The textbook is intended to serve as a workbook for the occupational therapy student. Numerous worksheets are provided throughout the book, and suggested answers are provided in the Appendix. It has been our experience that the worksheets function best as in-class activities after the student has reviewed the corresponding chapter prior to class. The worksheets can be completed individually, in pairs, or in small groups and then reviewed as a whole class. Worksheets can be assigned as homework, but our students have admitted at times to just copying the answers from the back of the book. Since learning the skill of documentation takes practice and clinical reasoning, we have found it more beneficial to have students complete the worksheets in class where it is more likely that they will demonstrate a true effort on the worksheets before checking their answers. It is also essential to reiterate to the students that the suggested answers in the Appendix are just one correct way to document. Just because his or her attempt looks very different from the suggested answer does not mean it is wrong. QUIZZES A few of the worksheets lend themselves nicely for use as an in-class quiz to assess comprehension of material presented in the chapter: Worksheet 4-1: Avoiding Common Documentation Errors Worksheet 6-2: Evaluating Goal Statements Worksheet 9-2: Justifying Continued Treatment Worksheet 11-3: SOAPing Your Note Depending on your students familiarity with the Occupational Therapy Practice Framework: Domain & Process, Second Edition, you can create a short quiz based on the information in Chapters 1 and 12 that tests the students understanding of how documentation is impacted by the Framework-II. Here are a few sample quiz questions: The Framework is divided into what two sections? List the categories for Areas of Occupation that an OT might address with a client. List the major steps in the Process of Service Delivery. List the parts of the evaluation process. Fill in the appropriate term for each of the following: (followed by the definitions of preparatory methods, purposeful activity, and occupation-based intervention) Other content in Chapter 4: General Guidelines for Documentation may also be used for quizzes. While it may seem ironic to give college students a quiz on grammar, punctuation, capitalization, and spelling, the authors have observed an alarming trend among students in recent years. Many students do not demonstrate proficiency in these basic writing skills. This lack of proficiency may be due to reliance on word processing programs to identify and correct errors. Regardless of the cause, these deficits have serious consequences for clinical documentation. One of the authors recently kept a list of misspelled words in student documentation over the course of a semester. Unfortunately, Table 4-2: Commonly Misspelled Words from the text is only an abbreviated version of that list. While some students may argue that the content of a note is more important than the presentation, we stand firmly in the belief that error-laden documentation reflects poorly on the student or clinician, the academic Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

4 Chapter 1 institution, the department, and occupational therapy as a profession. With that in mind, it is much better for them to miss a few points in class and learn the correct methods than to go out to a fieldwork site or entry-level position and make those errors. Table 4-3 from the text lists several commonly used abbreviations in occupational therapy settings. While many students will have already had a course in medical terminology prior to or since admission to your OT program, this list serves as a nice review and can also be used in whole or part for quiz purposes. It is, however, important to reiterate to students that the list is intended only for use in this specific textbook. Different facilities will have lists of acceptable and prohibited abbreviations. Be sure to let students know what abbreviations you consider acceptable in terms of your assignments to them. OTHER ASSIGNMENTS ICD AND CPT CODES Documentation and billing are inextricably linked. While ICD and CPT codes are frequently updated, it is useful for students to become familiar with the use of codes in general as part of their documentation. There are several reference guides, both printed and online, that provide explanations of commonly used codes. Consider having your students determine the appropriate ICD code for a client s diagnosis and the appropriate CPT code for the services documented. DOCUMENTATION ASSIGNMENTS There is no better way to learn how to document than simply to practice doing it. The following pages contain sample assignments that can be used to document treatment sessions from the videos provided with the Instructor s Manual, other treatment sessions that you have recorded, or for observation of an actual client in a class or fieldwork setting. These can be used as in-class or homework assignments. The following forms and corresponding grading rubrics are provided for you to adapt or edit according to your needs: Writing Functional Problem Statements Writing Goals The COAST Method Writing an Intervention Plan Writing a SOAP Note When students are first learning to document, the process can seem overwhelming. The first two assignments (Writing Functional Problem Statements and Writing Goals The COAST Method) break down the process into manageable steps for the student. The third assignment (Writing an Intervention Plan) combines the concepts of the first two assignments and adds in the requirement for the student to identify interventions to address the client s problems and goals. The final assignment (Writing a SOAP Note) assesses the student s understanding of all the concepts presented in the textbook. Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

Instructor s Manual 5 WRITING FUNCTIONAL PROBLEM STATEMENTS Name: Client: Date: Identify at least 2 strengths and 2 problems for the client observed. List more if applicable. Strengths Problems For each problem you have identified, write a functional problem statement using one of the three formulas found in Chapter 5: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

6 Instructor s Manual GRADING RUBRIC: WRITING FUNCTIONAL PROBLEM STATEMENTS Name: Points Points Criteria Possible 2 Professional presentation (typed or black ink), neat, legible, signed appropriately, turned in on time At least 2 strengths and 2 problems identified 2 No grammar, spelling, or punctuation errors (.5 deduction per error) 2 Strengths and problems reflect accurately what was reported or observed 2 Wording is clear to the reviewer; each problem is distinct (not two ways of saying the same thing) 2 Each problem statement contains a clear area of occupation and contributing factor Total: 10 Comments: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

WRITING GOALS THE COAST METHOD Instructor s Manual 7 Name: Client: Date: For each problem identified, write at least one long-term goal (LTG) and one short-term goal (STG) for the client using the COAST method: C Client Client will perform O Occupation What occupation? A Assist Level With what level of assistance/independence? S Specific Condition Under what conditions? T Timeline By when? Remember that the individual elements of the goal can be rearranged as long as all essential elements are present. Refer to Chapter 6 for additional tips and examples of COAST goals. Use additional pages if necessary. Problem Statement #1: LTG: STG: Problem Statement #2: LTG: STG: Problem Statement #3: LTG: STG: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

8 Instructor s Manual GRADING RUBRIC: WRITING GOALS THE COAST METHOD Name: Points Points Criteria Possible 2 Professional presentation (typed or black ink), neat, legible, signed appropriately, turned in on time At least 1 LTG and 1 STG for each problem identified 2 No grammar, spelling, or punctuation errors (.5 deduction per error) 2 Goals are treatable in and appropriate to the clinical situation (outpatient, home health, inpatient, etc.) 2 Goals are measurable, observable, and realistic to the client and setting 2 Goals are occupation-based and demonstrate medical necessity (or educational necessity if appropriate) Treatment is indicated within the scope of OT practice and requires the skill of an OT practitioner 2 All COAST elements are present 2 Goals are concise and organized 1 Interventions are not used as goals Total: 15 Comments: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

Instructor s Manual 9 WRITING AN INTERVENTION PLAN Name: Client: Date: Develop an intervention plan for your client based on the problems and goals you have identified. For each long-term goal (LTG), you should identify at least two short-term goals (STGs). For each STG, you should identify at least two interventions. Be sure that your interventions include an appropriate mix of preparatory methods, purposeful activity, and occupation-based intervention. Refer to Chapter 12 in your textbook for tips and examples. Use additional pages if necessary. Problem: LTG: STGs (Objectives) STG #1: Interventions STG #2: Problem: LTG: STGs (Objectives) STG #1: Interventions STG #2: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

10 Instructor s Manual GRADING RUBRIC: WRITING AN INTERVENTION PLAN Name: Points Points Criteria Possible 2 Professional presentation (typed or black ink), neat, legible, signed appropriately, turned in on time At least 1 LTG and 2 STGs for each problem identified At least 2 interventions for each STG identified 2 No grammar, spelling, or punctuation errors (.5 deduction per error) 2 Goals are treatable in and appropriate to the clinical situation (outpatient, home health, inpatient, etc.) 2 Goals are measurable, observable, and realistic to the client and setting 2 Goals are occupation-based and demonstrate medical necessity (or educational necessity if appropriate) Treatment is indicated within the scope of OT practice and requires the skill of an OT practitioner 2 All COAST elements are present Goals are concise and organized 2 Interventions address the client s goals and are appropriate to the setting 1 Interventions contain an appropriate mix of preparatory methods, purposeful activity, and occupation-based intervention Total: 15 Comments: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

WRITING A SOAP NOTE Instructor s Manual 11 Name: Client: Date: Write a SOAP note for the client s OT session. Remember to include the essential elements for each section of the SOAP Note. Refer to the Quick Checklist found in the back of your textbook. S: O: A: P: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

12 Instructor s Manual GRADING RUBRIC: WRITING A SOAP NOTE Name: Points Points Criteria Possible 2 Professional presentation (typed or black ink), neat, legible, signed appropriately, turned in on time 2 No grammar, spelling, or punctuation errors (.5 deduction per error) 2 The S is relevant to the session and is accurate (if the client is quoted, the quote contains the client s exact words) The S is concise and coherent; the most relevant information has been selected rather than a list of things the client said 5 The O begins with where, for how long, and for what purpose the client received OT The O demonstrates that the skills of an OT practitioner were required The O contains accurate information with correct medical terminology and abbreviations Assist levels show what part of the task required assistance Response to client/caregiver education is noted when appropriate Intervention is described in terms of purpose and function, de-emphasizing the treatment media The O is written from the client s point of view using nonjudgmental language 5 The A contains a complete assessment of the data presented in the S and O Problems, progress, and/or rehab potential are clearly indicated No new material is presented in A that wasn t already discussed in S or O The A ends with a statement about what the client would benefit from There is adequate justification for continued skilled OT 2 The P contains information regarding frequency/duration of services and for what purpose the client will be seen The P contains a description of planned interventions to address the problems identified in the A The P is reasonable for this particular client and setting 2 Each SOAP category contains only the correct information for that category The entire note is complete, organized, and concise Total: 20 Comments: From Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes, third edition instructor s manual. Online document, http://www.efacultylounge.com, based on Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

Instructor s Manual 13 SAMPLE VIDEOS We have provided three videos that are useful to students in learning documentation. These videos can be used as in-class or homework assignments. If used in class, students can complete the assignment individually or work in small groups. A brief summary of each video is provided below. A more detailed case history and sample documentation for each video is provided on the pages that follow. 1. Mr. Suzuki (10.5 minutes): The client is a 71-year-old man who recently broke his hip. The session takes place in an inpatient hospital setting. The OT in the video is teaching him how to get dressed using adaptive equipment. 2. Mrs. Mulliver (8 minutes): The client is an 82-year-old woman who has macular degeneration. She has purchased a vision machine to enlarge print so that she will be able to see to read and write independently. The session takes place in her home, and the OT teaches her how to use the vision machine. 3. Coach (7 minutes): The client is a 67-year-old man who injured his knee and is now in a knee immobilizer. The session takes place in an outpatient clinic and in the parking lot outside. In this video, the OT instructs him on tub transfers and car transfers. In our course, we first provide the students with the case history. Next we briefly discuss what they anticipate seeing in the video. Then we have the students watch the video and write out problems, goals, and a SOAP note. When used as an in-class assignment, it is helpful for students to take notes during the video so they can refer back to them as they complete the documentation assignment. We also allow them to refer to the textbook for tips and examples as they complete the assignment. When students are first learning to document, it often takes them a very long time to complete a documentation assignment, sometimes 1 hour or longer. As they become more proficient, we increase the expectations. For example, we may allow them to take notes during the video but prohibit them from referring to the textbook, or only allow them to refer to the cardstock pullouts at the back of the book. As the semester progresses, we ask the students to watch a video without taking any notes and then to document without referring to the text or checklists. These three videos all address physical dysfunction and are intended for use in the early stages of learning documentation. These videos are staged situations created by one of the authors. We encourage you to develop similar videos for use in your classroom, particularly videos that cover other OT settings such as pediatrics or mental health. Faculty colleagues and local clinicians are great resources for this type of project. Ideally, you could have an actual client come to class for an OT session and have students document about that session. MR. SUZUKI HISTORY When Mr. Suzuki was 18 years old, he immigrated to the United States from his native Japan to accept a scholarship to the university. His culture places a high value on education and has great respect for teachers, so Mr. Suzuki became a high school math teacher. He is a small man, and he wondered how he would discipline the large boys, but luck was with him. The students assumed that he was a martial artist because he is Asian, and he never corrected them. When one of the boys asked him if he had a black belt, he replied, Yes, knowing that in his closet was the black leather belt he wore with his Sunday suit trousers. Mr. Suzuki values his health and has always kept himself fit, even as he has aged. At 71, he is still healthy, even though he does not hear as well as he once did and sometimes misses auditory cues. One day at the Fitness Center, he stepped onto a treadmill without realizing that its user had left it running and gone to the bathroom. Mr. Suzuki fell and broke his hip. He was admitted to Lewis and Clark Hospital for a total hip replacement. The hospital uses a critical care pathway for hip replacements that calls for a 4-day length of stay with specific interventions for each discipline (see Table 12-1 in your text). This is day 2 of the program. Mr. Suzuki is embarrassed by the idea of being seen using a walker. He places great value on saving face and does not want the boys who always thought he was a martial artist to see him limping. His granddaughter is getting married in 3 months, and he plans to walk her down the aisle in her father s place. He is motivated to work hard to return his body to a state of fitness in order to walk normally again. Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

14 Instructor s Manual MRS. MULLIVER HISTORY Mrs. Mulliver is an 82-year-old woman who has macular degeneration, resulting in low vision. She lives at home with her 85-year-old husband, who also has a disabling condition (CVA 6 years ago). The Mullivers were childhood sweethearts and have been married for 61 years. They have 3 grown children and 5 grandchildren. Dr. Mulliver has been successful in his career as a surgeon and the Mullivers are comfortably well-off financially. As Mrs. Mulliver s vision has worsened, she has become less and less independent in her IADL activities. She loves to cook but can no longer read recipes or packages. She has always been the one to manage the family finances, but she can no longer see well enough to write a check. Dr. Mulliver is willing to help her or to take over some of the roles and tasks that have always been hers, but Mrs. Mulliver values her independence and her ability to make a contribution to the household. She wants to be able to continue with some of her most prized roles. The Mullivers have ordered a Spectrum III machine to enlarge print so that Mrs. Mulliver can read it. When it was delivered earlier in the week, Dr. Mulliver called the local Home Health Agency to request that an occupational therapist come out and teach his wife how to use the new machine. The Mullivers have received services from the Home Health Agency in the past and are acquainted with the agency. They are private-pay clients, so there is no concern about what is covered under Medicare. Laura is the occupational therapist who will be visiting Mrs. Mulliver today. She is a recent graduate who began working for the agency a few months ago. She is acquainted with the Spectrum III and has reviewed its functions to be sure she will be able to teach its use easily. She is a little nervous because she has never met the Mullivers and wonders what they will be like. COACH HISTORY John Darling is a 67-year-old white male who coached high school sports for 41 years prior to his retirement 2 years ago. Since the name Darling was a major source of amusement for high school students, he started going by the name Coach early in his career. After a few years, even his family and friends began to call him Coach, and it became his identity. Although retired, he still loves sports and young people, and now volunteers to coach a team of disadvantaged youth in Two Mile Prairie, about 25 miles north of his home town. On Saturday, he was demonstrating a play when he stepped in a hole and was hit from the side, landing underneath 2 of the larger boys. Coach ended up with a spiral fracture of the distal femur of his right leg. He was taken to Two Mile Prairie General Hospital, where an open reduction internal fixation was done on an emergency outpatient basis. He was sent home with pain medication and a knee immobilizer and told not to bear weight on his right leg for 3 to 4 weeks. He took the pain medication and slept most of Sunday. First thing Monday morning he called his primary care physician. Knowing she was wasting her breath, the PCP nonetheless lectured Coach on what a 67-year-old man should and should not be doing as it pertains to football. She scheduled an appointment to see him on Thursday and ordered outpatient OT and PT (2 to 3 visits each) to get Coach some education on proper ways to maintain his non-weightbearing status and also to get him started on a good home exercise program. Suzanne, the occupational therapist, and Mark, the physical therapist at Two Mile Prairie Outpatient Therapy, have worked together for several years and work well together. Mark saw Coach this morning to fit the walker and teach Coach how to use it properly. He will be doing some gentle PROM and starting Coach on a home program of strengthening exercises as healing progresses. He plans to ask for more visits to work on ambulation when Coach is ready to begin some weightbearing When Suzanne asked Coach what his priorities were, his first two priorities were to be able to take a bath and to be able to get in and out of the car. The physician told him that he could take off the immobilizer after he was sitting in the bathtub, and that he could take it off in physical therapy, but otherwise he was to wear it 24/7. Since Coach cannot reach his feet, he will need some adaptive equipment and techniques for dressing also, but Suzanne plans to start with tub and car transfers since that is what Coach wants to do most. His wife has taken a week off work to take care of him this first week, and she has been helping him with things like dressing. Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

SAMPLE DOCUMENTATION FOR VIDEOS Instructor s Manual 15 Each of the three videos is brief, and we explain to students that the video represents one portion of a longer treatment session that is approximately 30 minutes in length. We have included sample documentation for each of the videos that may be helpful as you grade student assignments or as an example to show the class when their graded assignments are returned to them. Just as we tell our students, please remember that these samples are not the only correct way to document. MR. SUZUKI Problem #1: Client requires adaptive equipment and verbal cues to complete lower body dressing due to hip precautions. LTG: By discharge in 2 days, client will complete lower body dressing with modified independence using adaptive equipment and maintaining all hip precautions. STG: Client will don pants with SBA using dressing stick by tomorrow s ADL session. STG: Client will don socks and shoes with modified independence using adaptive equipment by tomorrow s ADL session. Problem #2: Client requires verbal cues to follow hip precautions during ADLs due to unfamiliarity with the hip precautions. LTG: By discharge in 2 days, client will complete all basic ADLs with modified independence while demonstrating compliance with hip precautions. STG: Client independently will verbalize 3/3 hip precautions for safety during ADLs by next treatment session. STG: Client will complete grooming tasks standing at sink with walker with no more than 1 verbal cue for hip precautions by tomorrow s ADL session. STG: Within 2 sessions, client will complete toileting with using commode frame and walker with no more than 1 verbal cue for hip precautions. Students often want to attribute the client s inability to recall the hip precautions to a cognitive deficit or decreased short-term memory. This is a good opportunity to point out that a client s unfamiliarity with the new rules he has been given is simply due to a lack of experience with this situation, not a lack of intellectual ability. Additionally, some students document the contributing factor as due to THR. This is an opportunity to remind students that the diagnosis in not the contributing factor. In this case, it is the postsurgical restrictions that have been imposed on the client. Some students have difficulty coming up with other goals since the video focuses very specifically on lower body dressing. This is where clinical reasoning comes in. Ask the students questions like, Based on what you know about Mr. Suzuki, what other problems might he be having? or What areas of occupation are impacted by his deficits? Also refer them again to Table 12-1, which lists the clinical pathway for a total hip replacement. Other possible LTGs include: By discharge, client will complete grooming tasks standing at sink using walker with modified independence, following all hip precautions. By discharge, client will complete bathing with modified independence using tub bench and long-handled sponge, following all hip precautions. By discharge, client will demonstrate transfer in/out of car with modified independence while adhering to hip precautions. We have also encountered several students who want to write goals for ambulation since walking is heavily emphasized in the client s history. OTs very often encounter clients who respond, I want to walk when asked about their personal goals, but the physical therapist will be addressing ambulation. This video is a good opportunity for students to learn to focus on occupation, while still addressing the issue of safe ambulation during occupational performance. For example, consider these goals for Mr. Suzuki: By discharge, client will retrieve clothing from closet with modified independence using walker for safety during ambulation. Client will prepare a snack in rehab kitchen with SBA using walker and wheeled cart for item retrieval and transport within 2 treatment sessions. Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

16 Instructor s Manual Here is an example of a SOAP note for Mr. Suzuki: S: When asked, client was able to state 1 of 3 hip precautions. O: Client participated in 30-minute bedside OT session for skilled instruction in compensatory techniques for lower body dressing. After set up, client donned socks using sock aide with min A for hand positioning and to thread sock onto device. Client donned pants with min A and verbal cues to position dressing stick. Verbal cues required to don shoes using long shoe horn. Client required 3 verbal cues to follow hip precautions during lower body dressing. Client able to sequence dressing tasks I, and spontaneously demonstrated problem solving to retrieve hard-to-reach items using reacher. Client I in upper body dressing from EOB. A: Inability to recall 2/3 hip precautions raises safety concerns in ADLs, IADLs, and functional mobility. Inability to remember all hip precautions and correct use of adaptive equipment necessitates assistance and verbal cueing to dress lower body safely. Ability to remember one hip precaution shows progress. Ability to sequence task and problem indicates good potential for return home with modified independence. Client would benefit from continued skilled instruction in hip precautions and adaptive equipment/techniques in ADL tasks as well as IADL tasks. P: Continue OT b.i.d. for 30-minute sessions for 2 more days to increase ability to follow hip precautions in ADL and IADL tasks. OT to address dressing, toileting, bathing, snack preparation, and car transfers by discharge. MRS. MULLIVER This OT session is unique in that funding justification is not an issue as this is a private-pay client. Also, based on the interaction at the end of the video, we know that the OT plans to see the client just one more time after this. This is a great opportunity to explain to students that OT evaluation and intervention often overlap. The OT in this video is assessing the client s performance while she is instructing her in the use of the vision machine. For purposes of documentation, it may be helpful to stop the video after the first 45 seconds and have the students write a problem statement, one long-term goal for the next session, and a few short-term goals for the existing session. Then have the students watch the remainder of the video and write a SOAP note. Problem: Client requires visual enlargement tool to read and write small print needed for home management tasks 2 to low vision. LTG: After 2 treatment sessions, client will complete IADL activities involving small print with modified I using the Spectrum III print enlargement machine. STG: After 1 treatment session, client will be able to read a recipe using the Spectrum III with min verbal cues for use of machine features. STG: After 1 treatment session, client will be able to locate a number in the telephone directory using the Spectrum III with min verbal cues for machine features. STG: After 1 treatment session, client will be able to write a check using the Spectrum III with min verbal cues for machine features. S: Client reports having difficulty reading small print. She would like to be able to find numbers in the phone book, read recipes, and write checks independently. At the end of the session, she reported finding the Spectrum III very helpful in reading and writing. O: Client participated in 30-minute OT session in her home for skilled instruction in the use of the Spectrum III print enlargement machine for reading and writing tasks during IADLs. Following instruction in machine features (focus, color, brightness, size, and underline), client demonstrated ability to read a recipe and a number from the telephone directory with min verbal cues for use of machine features. Client also wrote a grocery list and a check with min verbal cues for use of machine features. A: Low vision impacts client s ability to read and write during IADL tasks. Ability to use Spectrum III with min verbal cues during today s session shows good progress toward stated goals. Client shows good potential to be independent in reading and writing any print item that can be placed in the Spectrum III. Client would benefit from one more visit to reassess independence with use of machine and instruct further as needed. P: Client to be seen for one more intervention session in one week to assess knowledge and understanding of the Spectrum III. Independence with reading and writing tasks using the Spectrum III during IADLs will be reassessed and additional skilled instruction provided as needed. Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.

COACH Instructor s Manual 17 This video is another example of intervention beginning during the first session. Based on the information provided in the client s history, we can assume that the OT in this video has already completed a brief evaluation and identified the priorities for intervention. Problem #1: Client unable to get in and out of tub and car safely and independently due to NWB status and inability to bend R knee with immobilizer. LTG: Within two sessions, client will complete tub and car transfers with modified independence using adaptive equipment and techniques. STG: By the end of the first treatment session, client will complete tub transfer with SBA using tub transfer bench. STG: By the end of the first treatment session, client will complete car transfer with SBA using adaptive techniques. S: Client reports difficulty getting in and out of the bathtub and car. O: Client participated in a 30-minute OT session in outpatient clinic for skilled instruction in safe transfers for ADLs and IADLs. Following instruction in sit/scoot/pivot method, client demonstrated understanding by repeating instructions and performed tub transfer X 2 with SBA using tub transfer bench. Min verbal cues were required for safe hand placement on tub bench. Using same technique, client transferred walker car with SBA, using plastic bag to facilitate scooting on seat. Min verbal cues required for adaptive technique and safety. Client also required assist to move walker following both tub and car transfers. A: R LE NWB status and inability to bend R knee due to immobilizer limit client s ability to transfer in and out of tub and car independently and safely. Same deficits also impact client s independence with dressing tasks. Progress with transfers in today s session and quick skill acquisition indicate excellent rehab potential. Client would benefit from reassessment of independence with transfers and skilled instruction in use of adaptive equipment and techniques for lower body dressing. P: Client will be seen 1 more 30-minute session to reassess safety and for skilled instruction in lower body dressing. Session will focus on skilled instruction and trial use of adaptive equipment including reacher, sock aid, dressing stick, and long shoe horn. While this video focuses specifically on functional transfers, students should be able to use their clinical reasoning skills and the information from the client s history to identify lower body dressing as another problem area to be targeted for intervention. The physician wrote orders for 2 to 3 visits of OT, but based on the client s fast progress in this session, it is likely that he will be able to master the use of adaptive equipment for lower body dressing in just one session. Therefore, only a long-term goal is necessary for this problem. Problem #2: Client requires assistance from caregiver for lower body dressing due to R knee immobilizer and NWB status. LTG: Client will complete lower body dressing with modified independence using adaptive equipment by end of next session. CONCLUSION We hope that you and your students find this textbook and instructor s manual useful. We invite your comments, criticisms, ideas, and suggestions for ways to improve this book. We also invite you to submit examples of documentation that you consider to be good examples for a particular practice setting. When submitting a note, please include your name, address, phone number, and e-mail so that the authors may contact you regarding permission to publish the note in future editions of this textbook. Please send your comments, suggestions, or notes to: Crystal Gateley, MA, OTR/L c/o SLACK Incorporated Professional Book Division 6900 Grove Road Thorofare, NJ 08086 Copyright 2012 SLACK Incorporated. Gateley, C. A., & Borcherding, S. (2012). Documentation manual for occupational therapy: Writing SOAP notes (3rd ed.). Thorofare, NJ: SLACK Incorporated.