The OTA's Guide to Documentation: Writing SOAP Notes

by Marie Morreale

Overview

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA's Guide to Documentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation while offering multiple opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos.

The Fifth Edition contains step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same easy-to-read format from previous editions to aid OTAs in learning the purpose and standards of documentation throughout all stages of the occupational therapy process and different areas of clinical practice.

Essentials of documentation, reimbursement, and best practice are reflected in the many examples presented throughout the text. Worksheets and learning activities provide the reader with multiple opportunities to practice observation skills and clinical reasoning, learn documentation methods, create occupation-based goals, and develop a repertoire of professional language.

Templates are provided to assist beginning OTA students in formatting occupation-based SOAP notes, and the task of documentation is broken down into smaller units to make learning easier. Other formats and methods of recording client care are also explained, such as the use of electronic health records and narrative notes. This text also presents an overview of the initial evaluation process delineating the roles of the OT and OTA and guidelines for implementing appropriate interventions.

New in the Fifth Edition:

Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documents

Updated information to meet Medicare Part B and other third-party payer requirements

Revised clinical terminology on par with current trends

Added examples from emerging practice areas

Expanded tables along with new worksheets and learning activities

Instructors in educational settings can visit www.efacultylounge.com for an Instructor's Manual and bonus videos to be used in the classroom. Also included with the book is access to a supplemental website for students with to be used in the classroom. Also included with the book is access to a supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.

Product Details

ISBN-13:	9781638220367
Publisher:	Taylor & Francis
Publication date:	08/15/2022
Edition description:	5th ed.
Pages:	352
Sales rank:	209,067
Product dimensions:	8.50(w) x 11.00(h) x 0.70(d)

About the Author

Marie J. Morreale, OTR, graduated Summa Cum Laude from Quinnipiac College (now Quinnipiac University) with a BS in occupational therapy. Throughout her professional career, Marie worked in a variety of practice settings, including inpatient and outpatient rehabilitation, cognitive rehabilitation, adult day care, skilled nursing facilities, home health, and hand therapy. She held the designation of Certified Hand Therapist for 25 years and served several years on a home health professional advisory committee, consulting on quality assurance issues.

For 17 years, Marie taught OTA students at Rockland Community College, State University of New York in Suffern as an adjunct faculty member. She taught a variety of courses there, which included Professional Issues and Documentation, Geriatric Principles, Occupational Therapy Skills, Advanced Occupational Therapy Skills, Therapeutic Activities, and Advanced Therapeutic Activities, in addition to serving brief ly as interim coordinator of the OTA Program.

Marie co-authored the second, third, and fourth editions of The OTA’s Guide to Documentation: Writing SOAP Notes. She also created the first and second editions of Developing Clinical Competence: A Workbook for the OTA and co-authored The Occupational Therapist’s Workbook for Ensuring Clinical Competence. In addition, she wrote a chapter on documentation for The Occupational Therapy Manager, Fifth Edition, and published several occupational therapy articles. For the past several years Marie has been a test item writer for American Occupational Therapy Association continuing education products. She is active in her condo community and enjoys anything travel related.

Table of Contents

Acknowledgments

About the Authors

Chapter 1        Documenting the Occupational Therapy Process

Chapter 2        The Health Record

Chapter 3        Billing and Reimbursement

Chapter 4        Using Professional Terminology

Chapter 5        Avoiding Common Documentation Mistakes

Chapter 6        Writing the “S”—Subjective

Chapter 7        Writing the “O”—Objective

Chapter 8        Tips for Writing a Better “O”

Chapter 9        Writing the “A”—Assessment

Chapter 10      Writing the “P”—Plan

Chapter 11      Documenting Special Situations

Chapter 12      Improving Observation Skills and Refining Your Note

Chapter 13      Making Good Notes Even Better

Chapter 14      Evaluation and Intervention Planning

Chapter 15      Goals and Interventions

Chapter 16      Documenting Different Stages of Intervention

Chapter 17      Documentation in Different Practice Settings

Chapter 18      Examples of Different Kinds of Notes

Appendix: Suggestions for Completing the Worksheets

Index

Editorial Reviews

Reviewer: Julie R Kalahar, MS, OTR/L(Lake Area Technical Institute)
Description: This book presents a systematic method for learning the art and science of documentation for the skilled occupational therapy services provided by occupational therapy assistants. This update of the 2007 edition includes the terminology from the second edition of AOTA's Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association, 2008).
Purpose: The purpose is to assist occupational therapy assistant students with learning and practicing documentation for skilled professional services across various service settings. More experienced OTAs who are re-entering the profession or moving to a new setting also could benefit from this highly structured and easy to follow book. It builds on readers' experience and increases their knowledge of professional recording, while including worksheets with every chapter so they can practice various documentation skills.
Audience: The intended audience is occupational therapy assistant students, but the book would be a wonderful reference for entry-level OTA practitioners as well as experienced OTA practitioners who are re-entering the field or expanding their experience to other practice settings. The authors have extensive experience in the area of OTA education.
Features: In addition to providing a systematic and updated edition on documenting the entire OT process, this book identifies common documentation mistakes as well as how to document in special situations and in various practice settings. This edition also addresses advancing the entry-level documentation experience by coaching learners how to make progress notes even better and providing rich examples of various kinds of notes. The number of examples and the numerous opportunities to complete workbook exercises provide readers with opportunities to apply exactly what each chapter addresses.
Assessment: This is an excellent addition to references for OTA students and OTA practitioners re-entering the field or changing practice settings. Due to the constant evolution in healthcare settings, an update of documentation issues and principles is needed.

Doody's Review Service

The usefulness of this manual lies in its emphasis on promoting occupation and the occupational therapy input within written documentation.  It stresses the value of this level of transparency as a means of demonstrating the unique contribution of the occupational therapist to the service user’s health, wellbeing, and progress within a variety of care systems…This manual would be useful for those wishing to maintain or improve their standards of written documentation, practice educators, or educators teaching students to engage with occupational therapy documentation, as well as students who may want extra practice at this vital professional skill.”

- Ailsa Gillen, NHS Lothian, British Journal of Occupational Therapy

From the Publisher