Documenting Occupational Therapy Practice

Taking a global look at documentation in occupational therapy, this book examines both the technical, ";how-to"; aspect of all forms of clinical, school-based, and administrative documentation, and the ethical, legal, and language issues related to documentation. Soap notes as well as other forms of documentation are discussed throughout. Sections in this book include: Use of Language, Ethical and Legal Considerations ,Clinical Documentation, School System Documentation, and Administrative Documentation. There are also extensive appendices on AOTA Standards of Practice, AOTA Guidelines to Occupational Therapy Documentation, and AOTA Code of Ethics. This book can be used by students to learn about documentation and by clinicians to improve the quality of documentation in the field.

For many years, I wished for a book that could be used by students to learn about documentation, while at the same time be used by clinicians to improve the quality of documentation in the field. Eventually, I realized that I could, and should, write that book. As a college professor, I spend a great deal of time reading written work produced by occupational therapy students. As a peer reviewer, I read client charts that insurance companies are unsure about; the charts that are so poorly written that the insurers cannot decide whether the services are medically necessary and appropriate.

For these reasons, I decided to begin the long and challenging task of writing this book. It has taken over three years from the time I started talking about writing it to the actual printing of the book. Federal rules and professional standards changed while I was writing this book, forcing me to revise and add topics as the book evolved.

During the process of writing this book, I learned even more about writing. I learned that I write better in the morning than in the afternoon. I learned that I have difficulty knowing when to use the word "that" (refers to a specific object) as opposed to the word "which" (not specific to an object). I learned the difference between "assure" (to convince or to promise) and "ensure" (to make certain). I learned about comma and semicolon placement in sentences. Just because I pause when I speak the sentence out loud does not mean that rules of proper punctuation call for a comma. I learned the difference between a hyphen, an em dash, and an en dash. Finally, I learned to say "finally," instead of "lastly."

My hope for this book is that it gets used; that it is not simply put up on a shelf. I want it to be written in, to have pages flagged, and to have the spine well broken from repeated use. Normally, I would be appalled at the vision of food-stained, rumpled pages in a textbook. But I think this book is different. If it retains its original pristine condition, then it hasn't served its reader well.