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Documentation Manual for Occupational Therapy Writing SOAP Notes



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Slack Incorporated
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This is the 3rd edition with a publication date of 8/15/2011.

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As the practice of occupational therapy evolves, so too should the resources that aid clinicians, faculty, and students in learning and achieving the skill of effective documentation. Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Editionis designed to provide each part of the documentation process, while the worksheets are designed to let you practice each step as you learn it. Crystal A. Gateley and Sherry Borcherding take the Third Edition and broaden the scope of the text to include SOAP notes relevant to pediatric practice, driving assessment, balance, assistive technology, positioning and mobility, and other practice settings. Additionally, the authors have introduced in this updated edition, the COAST method of goal writing that emphasizes client-centered and occupation-based intervention and documentation. Also included in the Third Edition, new online instructor's material that includes videos, scenarios, corresponding documentation, sample grading rubrics, and assignments As in the previous editions, Documentation Manual for Occupational Therapy: Writing SOAP Notes, Third Editionfocuses specifically on documentation of client performance in occupational therapy practice. The proven ;how to ; strategy of this workbook translates the SOAP note process into a step-by-step sequence. Features of the Third Edition Include: " Worksheets designed to practice individual skills as well as the entire SOAP note process " New chapter on reimbursement, legal, and ethical consideration " New chapter on general guidelines for documentation " Instructor's material that includes videos, scenarios, corresponding documentation, sample grading rubrics, and assignments " Additional on-line resources available with new book purchase " Current information including AOTA's Centennial Vision, the Occupational Therapy Practice Framework: Domain & Process, 2nd Edition, and other AOTA Official Documents. Instructors in educational settings can visit for additional material to be used for teaching in the classroom. Documentation Manual for Occupational Therapy, Third Editionpresents essential documentation skills that all occupational therapy clinicians, faculty, and students will find critical for when assessing, treating, and offering the best evidence available for their clients.

Author Biography

Crystal A. Gateley, MA, OTR/L currently serves as a faculty member at University of Missouri in Columbia where she has taught since 2009. She teaches Foundations of Occupation, Developmental Framework, Pediatric Fieldwork, Clinical Documentation, and Health & Wellness. She has also taught Advanced Strategies and Problem-Based Cases. Crystal also assists with supervising occupational therapy students at the program’s on-site pediatric clinic.  

Crystal graduated Summa Cum Laude from University of Missouri with a BHS in occupational therapy and went on to complete her master’s in educational leadership and policy analysis (ELPA), also from the University of Missouri. She is currently pursuing a doctoral degree in ELPA from the University of Missouri. Crystal has worked in a variety of OT practice settings, including inpatient and outpatient rehabilitation, long-term care, home health, outpatient pediatrics, public schools, and sheltered workshops.    

Besides teaching, Crystal enjoys attending her daughters’ extracurricular events, including soccer, basketball, and band. She also loves camping, fishing, and boating with family and friends.    

Sherry Borcherding, MA, OTR/L recently retired from the faculty of University of Missouri where she taught for 15 years. During the time she was on faculty, she taught disability awareness; complementary therapy; clinical ethics; frames of reference; psychopathology; loss and disability; long-term care; wellness; and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. Two of her courses were designated as campus writing courses and one was credentialed for computer and information proficiency. As a part of the fieldwork and documentation courses, she filmed simulated occupational therapy interventions for student use in class. Three of those “movies” are available on with this edition of the book.    

Sherry graduated with honors from Texas Woman’s University, Denton with a BS in occupational therapy and went on to complete her master’s in special education with special faculty commendation at George Peabody College, Nashville, Tennessee. Following her staff positions in rehabilitation, home health, and pediatrics, she assumed a number of management roles including Chief Occupational Therapist at East Texas Treatment Center, Kilgore; Director of Occupational Therapy at Mid-Missouri Mental Health Center, Columbia; and Director of Rehabilitation Services at Transitional Housing Agency, Columbia, Missouri. She has also planned, designed and directed occupational therapy programs at Capital Regional Medical Center, Jefferson City, Missouri and at Charter Behavioral Health Center, Columbia, Missouri.   

Sherry is a lifelong learner. Since her retirement, she has further expanded her private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy at the techniques level through Upledger Institute, Palm Beach Gardens, Florida and is attuned as a Reiki master. For leisure, Sherry enjoys music, dance, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past few years.

Table of Contents

Dedication Acknowledgments About the Authors     Chapter 1            Documenting the Occupational Therapy Process   Chapter 2            The Health Record   Chapter 3            Reimbursement, Legal, and Ethical Considerations   Chapter 4            General Guidelines for Documentation   Chapter 5            Writing Functional Problem Statements   Chapter 6            Writing Measurable Occupation-Based Goals and Objectives   Chapter 7            Writing the \u201cS\u201d—Subjective   Chapter 8            Writing the \u201cO\u201d—Objective   Chapter 9            Writing the \u201cA\u201d—Assessment   Chapter 10          Writing the \u201cP\u201d—Plan   Chapter 11          Making Good Notes Even Better   Chapter 12          Intervention Planning   Chapter 13          Documenting Different Stages of Service Delivery   Chapter 14          Documentation in Different Practice Settings   Chapter 15          Examples of Different Kinds of Notes     References Appendix: Suggestions for Completing the Worksheets Index

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