The OTA's Guide to Documentation: Writing SOAP Notes

The OTAs Guide to Documentation: Writing SOAP Notes, Fifth Edition is the bestselling occupational therapy assistant (OTA) textbook, providing step-by-step instruction on occupational therapy documentation and the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. It includes examples from emerging practice areas and expanded tables, and online supplemental materials for faculty use in the classroom.

Format: Paperback / softback
Length: 352 pages
Publication date: 15 August 2022
Publisher: SLACK Incorporated

The bestselling, newly updated occupational therapy assistant (OTA) textbook, The OTAs Guide to Documentation: Writing SOAP Notes, Fifth Edition, delves into the critical skill of documentation while providing numerous opportunities for OTA students to practice documentation through learning activities, worksheets, and bonus videos. The Fifth Edition offers comprehensive step-by-step guidance on occupational therapy documentation, encompassing the legal, ethical, and professional documentation standards required for clinical practice and reimbursement of services. Students and professors alike can expect the same user-friendly format from previous editions, aiding OTAs in understanding the purpose and standards of documentation throughout all stages of the occupational therapy process and across various areas of clinical practice.

Essentials of documentation, reimbursement, and best practice are intricately reflected in the numerous examples showcased throughout the text. Worksheets and learning activities offer the reader multiple avenues to hone observation skills and clinical reasoning, acquire documentation methods, formulate occupation-based goals, and cultivate 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 facilitate easier learning. Other formats and methods of recording client care, such as the use of electronic health records and narrative notes, are also explained. This text also provides an overview of the initial evaluation process, outlining the roles of the OT and OTA and providing guidelines for implementing appropriate interventions.

New in the Fifth Edition:
Incorporation of the Occupational Therapy Practice Framework: Domain and Pro.

Dimension: 279 x 216 (mm)
ISBN-13: 9781638220367
Edition number: 5 Revised edition