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One of the most critical skills that occupational therapists must learn is effective documentation.
With that idea in mind, Documentation Manual for Occupational Therapy: Writing SOAP Notes, Fourth Edition presents a systematic approach to a standard form of health care documentation: the SOAP note. 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 new Fourth 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.
Documentation Manual for Occupational Therapy, Fourth Edition also includes the COAST method, a specific format for writing occupation-based goals.
Crystal Gateley and Sherry Borcherding use a “how-to” strategy by breaking up 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. In addition, examples from a variety of practice settings are included as a reference. Although this text addresses documentation in occupational therapy practice, the concepts can be generalized across other health care disciplines as well.
New in the Fourth Edition:
The chapter focusing on reimbursement, legal, and ethical considerations has been vastly expanded to provide an overview of sources of reimbursement, regulatory guidelines, and legal and ethical issues.
A new chapter focusing on electronic documentation has been added to illustrate how the concepts presented in this text can be used in various electronic documentation software products.
Faculty will have access to 12 videos that can be used for instructional purposes and documentation practice.
This edition includes an expanded Instructor’s Manual with sample quiz questions for several of the chapters, templates and grading rubrics for documentation assignments, and other instructional resources.
Instructors in educational settings can visit www.efacultylounge.com for additional material to be used for teaching in the classroom.
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.
Crystal A. Gateley, PhD, OTR/L is Associate Chair and Associate Teaching Professor at University of Missouri in Columbia, where she has taught since 2009. She teaches a variety of courses across the curriculum including Foundations & Theory in OT, Clinical Pathophysiology, Human Development & Occupations I and II, Level I Fieldwork, and Clinical Reasoning & Documentation.
Crystal graduated Summa Cum Laude from University of Missouri with a BHS in Occupational Therapy and went on to complete a master’s and doctorate in Educational Leadership and Policy Analysis (ELPA), also from University of Missouri. Crystal has worked in a variety of occupational therapy practice settings, including acute care, inpatient and outpatient rehabilitation, skilled nursing, home health, outpatient pediatrics, public schools, and sheltered workshops.
Besides teaching, Crystal enjoys attending her daughters’ extracurricular events, particularly Southern Boone Lady Eagles soccer and basketball, and frequently volunteers her time to support school and community organizations. She also loves camping, fishing, canoeing, and boating with family and friends.
Sherry Borcherding, MA, OTR/L is 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. Twelve of those “movies” are available on www.efacultylounge.com with this edition of the book.
Sherry graduated with honors from Texas Woman’s University, Denton, Texas 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, Texas; 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, English country dance, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past several years. She volunteers with the Community Emergency Response Team doing logistics.
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 Occupation-Based Problem Statements Chapter 6 Writing Measurable Occupation-Based Goals and Objectives Chapter 7 Writing the “S”—Subjective Chapter 8 Writing the “O”—Objective Chapter 9 Writing the “A”—Assessment Chapter 10 Writing the “P”—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 Electronic Documentation Chapter 16 Examples of Different Kinds of Notes
Appendix: Suggestions for Completing the Worksheets Index