Documentation Manual for Occupational Therapy

Crystal Gateley

• Publisher: Routledge
• Year: 2024
• Print ISBN: 9781638220602
• eBook ISBN: 9781040138045
• Edition: 5
• Topic: Medicine
• Subtopic: Occupational Therapy

The best-selling, 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

Included with the text are online supplemental materials for faculty use in the classroom. Instructors in educational settings can visit the site for an Instructor's Manual with resources to develop an entire course on professional documentation or to use the textbook across several courses.

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. The newly updated and expanded Documentation Manual for Occupational Therapy, Fifth Edition, will help students master their documentation skills before they ever step foot into practice.

Table of contents

• Cover
• Half-Title Page
• Title Page
• Dedication
• Table of Contents
• Acknowledgments
• About the Author
• Chapter 1 Documenting the Occupational Therapy Process
• Chapter 2 The Health Record
• Chapter 3 Reimbursement, Coding, and Billing
• Chapter 4 Legal, Regulatory, and Ethical Considerations
• Chapter 5 General Guidelines for Documentation
• Chapter 6 Writing Occupation-Based Problem Statements
• Chapter 7 Writing Measurable Occupation-Based Goals and Objectives
• Chapter 8 Writing the “S”—Subjective
• Chapter 9 Writing the “O”—Objective
• Chapter 10 Writing the “A”—Assessment
• Chapter 11 Writing the “P”—Plan
• Chapter 12 Intervention Planning
• Chapter 13 Documentation in Different Practice Settings
• Chapter 14 Electronic Documentation
• Chapter 15 Examples of Notes Across Various Stages of Occupational Therapy Service Delivery
• Appendix Suggestions for Completing the Worksheets
• Index