Mastering Occupational Therapy Documentation: A Comprehensive Guide

As an occupational therapist, effective documentation is a critical skill that can make all the difference in delivering quality patient care. The Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition provides a systematic approach to mastering the SOAP note, a standard form of healthcare documentation.

The Importance of SOAP Note Documentation

The SOAP note is widely used in various healthcare settings, and the clinical reasoning skills underlying it can be adapted to fit the written or electronic documentation requirements of nearly any occupational therapy practice setting. With the Documentation Manual for Occupational Therapy, Fourth Edition, you’ll learn how to develop a systematic approach to documentation, ensuring that you’re providing the best possible care for your patients.

What’s New in the Fourth Edition

• Updated to reflect current information essential to contemporary occupational therapy practice, including the AOTA’s Occupational Therapy Practice Framework: Domain & Process, Third Edition
• Includes the COAST method, a specific format for writing occupation-based goals
• Expands on the chapter focusing on reimbursement, legal, and ethical considerations, providing an overview of sources of reimbursement, regulatory guidelines, and legal and ethical issues
• A new chapter on electronic documentation, illustrating how to apply the concepts presented in this text to various electronic documentation software products
• Faculty resources, including 12 videos for instructional purposes and documentation practice

A Step-by-Step Approach to Mastering Documentation

Authors Crystal Gateley and Sherry Borcherding break down the documentation process into a step-by-step sequence, providing numerous worksheets to practice each individual skill as well as the entire SOAP note process. Examples from a variety of practice settings are included as a reference, making it easy to apply the concepts to your own practice.

Relevance Beyond Occupational Therapy

While this text focuses on occupational therapy, the concepts and principles can be generalized across other healthcare disciplines, making it a valuable resource for any healthcare professional.

Get ready to take your documentation skills to the next level with the Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition. This comprehensive guide is essential for assessing, treating, and providing the best evidence-based care for your patients.