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It needs to be thorough!

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important for legal/insurance reasons

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Different across settings!

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It needs to be short to the point

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SOAP note format, short term goals, long term goals, 

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SOAP note format, short term goals, long term goals, 

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time consuming...

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S.O.A.P.

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It is different for every setting

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another therapist should be able to read it and pick up where you left off

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Can be time-consuming

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detailed orientated from observations but written concisely

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Many different forms of documentation

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Use accurate, appropriate OT lingo and medical terminology

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starts as soon as we enter the patients room

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Everything you did to protect you in the long run

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documentation = reimbursement for services

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Documentation is the on paper source for other professional personnel to look over. Putting thoughts on paper

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It needs to be short and sweet and provide great details.

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Documentation can be long but needs to be correct

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Documentation can be long but needs to be correct

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Time consuming

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different settings have different time frames it has to be turned in 

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different settings have different time frames it has to be turned in 

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Documentation needs to have accurate information for insurance companies to understand what you are doing in practice. It needs to be thorough, however some documentation varies across settings especially hand therapy compared to pediatric settings.

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different clinics have different sites/companies they use

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Covers your bases

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The note need to be thorough so that all other health professionals know what’s going on with the client.

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Correct spelling of clients name, etc or will be rejected by insurance company 

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Correct spelling of clients name, etc or will be rejected by insurance company 

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your analysis

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Important for others to be able to go back and see what happened last, if its not the same therapist