Documentation manual for occupational therapy / Crystal A. Gateley, PHD, OTR/L, Associate Chair & Associate Teaching Professor, Department of Occupational Therapy, University of Missouri - School of Health Professions, Columbia, Missouri, Sherry Borcherding, MA, OTR/L, Clinical Associate Professor, Retired, University of Missouri, Columbia, Missouri.

Revised edition of: Documentation manual for writing SOAP notes in occupational therapy / Sherry Borcherding. 4th edition, c2017.

Includes bibliographical references and index.

Documenting the occupational therapy process -- The health record -- Reimbursement, legal, and ethical considerations -- Legal, Regulatory, and Ethical Considerations -- General guidelines for documentation -- Writing measurable occupation-based problem statements -- Writing measurable occupation-based goals and objectives -- Writing the "S" subjective -- Writing the "O" objective -- Writing the "A" assessment -- Writing the "P" plan -- Making good notes even better -- Intervention planning -- Documenting different stages of service delivery -- Documentation in different practice settings -- Electronic documentation -- Examples of different kinds of notes -- Appendix -- Index.

"The newly updated occupational therapy textbook Documentation Manual for Occupational Therapy, Fifth Edition, is made for students and early-career practitioners learning the critical skill of documentation. The workbook format offers students ample opportunities to practice writing occupation-based problem statements and goals, intervention plans, SOAP notes, and other forms of documentation. The Fifth Edition has also been updated to reflect changes in the American Occupational Therapy Association's Occupational Therapy Practice Framework: Domain and Process, Fourth Edition. What's included in Documentation Manual for Occupational Therapy: - Numerous worksheets for students to practice individual skills with suggested answers provided in the Appendix - Updated information on coding, billing, and reimbursement to reflect recent Medicare changes, particularly in post-acute care settings - Examples from a variety of contemporary occupational therapy practice settings. One of the most critical skills that occupational therapy practitioners must learn is effective documentation to guide client care, communicate with colleagues, and maximize reimbursement."--Provided by publisher.