The OTA’s Guide to Documentation: Writing SOAP Notes

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 bonus 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.