"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 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"-- Provided by publisher.

Documenting the Occupational Therapy Process -- The Health Record -- Billing and Reimbursement -- Using Professional Terminology -- Avoiding Common Documentation Mistakes -- Writing the "S"-Subjective -- Writing the "O"-Objective -- Tips for Writing a Better "O" -- Writing the "A"-Assessment -- Writing the "P"-Plan -- Documenting Special Situations -- Improving Observation Skills and Refining Your Note -- Making Good Notes Even Better -- Evaluation and Intervention Planning -- Goals and Interventions -- Documenting Different Stages of Intervention -- Documentation in Different Practice Settings -- Examples of Different Kinds of Notes.