The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos.

The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice.

Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language.

Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions.

New in the Fifth Edition:

• Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents
• Updated information to meet Medicare Part B and other third-party payer requirements
• Revised clinical terminology on par with current trends
• Added examples from emerging practice areas
• Expanded tables along with new worksheets and learning activities

Instructors in educational settings can visit www.efacultylounge.com for an Instructor’s Manual and bonus videos to be used in the classroom. Also included with the book is access to a supplemental website for students with to be used in the classroom. Also included with the book is access to a supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.

Contents

Contents
Dedication
Acknowledgments
About the Author 

Chapter 1 Documenting the Occupational Therapy Process 
Chapter 2 The Health Record
Chapter 3 Billing and Reimbursement
Chapter 4 Using Professional Terminology 
Chapter 5 Avoiding Common Documentation Mistakes
Chapter 6 Writing the “S”—Subjective
Chapter 7 Writing the “O”—Objective
Chapter 8 Tips for Writing a Better “O”
Chapter 9 Writing the “A”—Assessment
Chapter 10 Writing the “P”—Plan
Chapter 11 Documenting Special Situations 
Chapter 12 Improving Observation Skills and Refining Your Note
Chapter 13 Making Good Notes Even Better
Chapter 14 Evaluation and Intervention Planning
Chapter 15 Goals and Interventions
Chapter 16 Documenting Different Stages of Intervention
Chapter 17 Documentation in Different Practice Settings
Chapter 18 Examples of Different Kinds of Notes

Appendix: Suggestions for Completing the Worksheets 
Index

About the Editors

Marie J. Morreale, OTR, graduated Summa Cum Laude from Quinnipiac College (now Quinnipiac University) with a BS in occupational therapy. Throughout her professional career, Marie worked in a variety of practice settings, including inpatient and outpatient rehabilitation, cognitive rehabilitation, adult day care, skilled nursing facilities, home health, and hand therapy. She held the designation of Certified Hand Therapist for 25 years and served several years on a home health professional advisory committee, consulting on quality assurance issues.

For 17 years, Marie taught OTA students at Rockland Community College, State University of New York in Suffern as an adjunct faculty member. She taught a variety of courses there, which included Professional Issues and Documentation, Geriatric Principles, Occupational Therapy Skills, Advanced Occupational Therapy Skills, Therapeutic Activities, and Advanced Therapeutic Activities, in addition to serving brief ly as interim coordinator of the OTA Program.

Marie co-authored the second, third, and fourth editions of The OTA’s Guide to Documentation: Writing SOAP Notes. She also created the first and second editions of Developing Clinical Competence: A Workbook for the OTA and co-authored The Occupational Therapist’s Workbook for Ensuring Clinical Competence. In addition, she wrote a chapter on documentation for The Occupational Therapy Manager, Fifth Edition, and published several occupational therapy articles. For the past several years Marie has been a test item writer for American Occupational Therapy Association continuing education products. She is active in her condo community and enjoys anything travel related.