Documenting Occupational Therapy Practice

A comprehensive guide to creating effective documentation in occupational therapy.

Documenting Occupational Therapy Practice, 3/e is the most comprehensive text on occupational therapy documentation currently on the market, covering general documentation principles, clinical documentation, electronic documentation, school system documentation, and documentation of administrative tasks. More than just a how-to manual, the text explores important ethical, legal, and language issues related to documentation in addition to presenting step-by-step strategies for creating successful SOAP notes, communications, and documentation. The Third Edition has been fully updated to reflect current AOTA official documents and new electronic documentation tools, and has been reorganized to improve readability. Effective review tools help readers truly master documentation techniques and strategies, while the text’s accompanying website provides additional learning resources that can be accessed on the go.

Teaching and Learning Experience

This text offers a comprehensive guide to creating effective documentation for occupational therapy. It provides:

• Comprehensive coverage of all areas of practice: Chapters examine the underlying concepts of good documentation in clinical, school, and administrative settings.
• Practical techniques and strategies that prepare students for the workplace: Chapters present clear, effective strategies for drafting documentation and communication that can be directly applied in professional settings.
• Exploration of ethical and legal issues: Discussions help students understand how documentation affects others and provide problem-solving strategies for addressing legal and ethical issues.
• Coverage of electronic documentation: Screenshots and discussion of electronic health record (EHR) systems familiarize students with current documentation technologies.
• Effective learning tools: Review exercises and numerous reference tools help students truly master text material.

Here is what people are saying:

“The depth and breadth…clearly outshines any other work on the subject I have seen.”–William R. Croninger, MA, OTR/L University of New England 

“The author has a style that is entertaining, yet factual.  She manages to make a potentially deadly topic interesting, funny and informative.”–Cathy Nielson, MPH, OTR/L, The University of North Carolina at Chapel Hill

“This text provides a complete knowledge base of information related to documentation that will serve readers well throughout their professional careers.” —Kathy Clark Tuminski, MA, OTR/L  University of Kentucky

Taking a global look at documentation, Documenting Occupational Therapy Practice examines both the technical, “how-to” aspects of clinical, school-based, and administrative documentation, and the ethical, legal and language issues related to occupational therapy documentation.  Chapters on terminology, frames of reference, jargon and abbreviations address the language that is necessary for good documentation.  SOAP notes as well as other forms of documentation are discussed throughout.

This is an ideal book for use both in the occupational therapy curriculum as well as in the field!

Features include:

• Presents the new Framework for Occupational Therapy Practice (AOTA).
• Different forms of documentation--in a variety of clinical and school settings--are provided throughout.
• Exercises in every chapter reinforce learning.  Suggested answers to these activities are provided within Appendix A.
• Sample reproducible forms are included in Appendix G can be used for hands-on practice.
• Appendix B:  ‘Grammar and Spelling Review’ points out the most common grammar and spelling mistakes to help the user provide accurate and effective documentation.