The OTA's Guide to Documentation

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTA’s Guide toDocumentation: Writing SOAP Notes, Fifth Edition explains the critical skill of documentation whileoffering multiple opportunities for OTA students to practice documentation through learningactivities, worksheets, and bonus videos.The Fifth Edition contains step-by-step instruction on occupational therapy documentation and thelegal, ethical, and professional documentation standards required for clinical practice andreimbursement of services. Students and professors alike can expect the same easy-to-read formatfrom previous editions to aid OTAs in learning the purpose and standards of documentationthroughout 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 examplespresented throughout the text. Worksheets and learning activities provide the reader withmultiple opportunities to practice observation skills and clinical reasoning, learn documentationmethods, 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. Otherformats and methods of recording client care are also explained, such as the use of electronichealth records and narrative notes. This text also presents an overview of the initial evaluationprocess delineating the roles of the OT and OTA and guidelines for implementing appropriateinterventions.New in the Fifth Edition:Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Fourth Edition and other updated American Occupational Therapy Association documentsUpdated information to meet Medicare Part B and other third-party payer requirementsRevised clinical terminology on par with current trendsAdded examples from emerging practice areasExpanded tables along with new worksheets and learning activitiesIncluded with the text are online supplemental materials for faculty use in the classroom, this includes: access to supplemental website worksheets, learning activities, and scenario-based videos to practice the documentation process.