Mastering Documentation in Occupational Therapy: A Comprehensive Guide

Effective documentation is a crucial skill for occupational therapists, and Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition provides a systematic approach to mastering this essential skill. This updated edition presents a step-by-step guide to creating high-quality SOAP notes, a standard form of healthcare documentation.

Improve Clinical Reasoning and Adapt to Any Practice Setting

The clinical reasoning skills underlying SOAP note documentation can be adapted to fit the written or electronic documentation requirements of nearly any occupational therapy practice setting. This edition has been updated to reflect current information essential to contemporary occupational therapy practice, including the AOTA’s Occupational Therapy Practice Framework: Domain & Process, Third Edition.

COAST Method for Writing Occupation-Based Goals

The COAST method, a specific format for writing occupation-based goals, is included to help occupational therapists create effective and measurable goals. This method can be applied to a variety of practice settings, making it a valuable tool for occupational therapy clinicians, faculty, and students.

Step-by-Step Guidance and Practical Examples

Authors Crystal Gateley and Sherry Borcherding use a how-to strategy, breaking down the documentation process into a step-by-step sequence. Numerous worksheets are provided 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 easier to apply the concepts to real-world situations.

New in the Fourth Edition

The chapter on reimbursement, legal, and ethical considerations has been expanded to provide an overview of sources of reimbursement, regulatory guidelines, and legal and ethical issues. A new chapter on electronic documentation has been added, illustrating how the concepts presented in this text can be used in various electronic documentation software products.

In addition, faculty will have access to 12 instructional videos that can be used for teaching and documentation practice. Instructors in educational settings can visit the eFaculty Lounge for additional material to support teaching in the classroom.

Essential Documentation Skills for Occupational Therapy Clinicians

Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition presents essential documentation skills that all occupational therapy clinicians, faculty, and students will find critical for assessing, treating, and offering the best evidence available for their clients. By mastering the skills outlined in this text, occupational therapists can improve patient outcomes, enhance their professional practice, and stay current with the latest developments in the field.