The OTA’s Guide to Documentation: Writing SOAP Notes, Fifth Edition, a best-selling and recently updated textbook for occupational therapy assistants (OTAs), explains the crucial skill of documentation and provides numerous opportunities for OTA students to practice it through worksheets, bonus videos, and learning activities.
Step-by-step instructions on occupational therapy documentation and the professional, ethical, and legal documentation requirements necessary for clinical practice and service reimbursement are included in the Fifth Edition. In order to help OTAs understand the goal and standards of documentation throughout all stages of the occupational therapy process and various areas of clinical practice, both instructors and students should anticipate the same approachable format from earlier editions.
The numerous examples provided throughout the work illustrate key concepts related to documentation, reimbursement, and best practices. The reader is given several opportunities to practice clinical reasoning and observation abilities, master documentation techniques, set goals based on their occupation, and expand their vocabulary in formal language through worksheets and learning activities.
Beginning OTA students can format occupation-based SOAP notes with the help of templates, and learning is facilitated by breaking down the documentation work into smaller sections. The use of narrative notes and electronic health records, among other forms and techniques for documenting client care, are also covered. Along with outlining the duties of the OT and OTA and providing instructions for putting appropriate interventions into practice, this work also provides an overview of the initial evaluation procedure.
The Fifth Edition now includes the Fourth Edition of the Occupational Therapy Practice Framework: Domain and Process, along with other updated publications from the American Occupational Therapy Association.
updated data in compliance with third-party payer regulations and Medicare Part B
updated clinical terminology to reflect current practices
Further illustrations from developing practice areas
enlarged tables combined with fresh worksheets and educational exercises
For an Instructor’s Manual and other films to use in the classroom, educators can visit www.efacultylounge.com. Access to an additional website for students to utilize in the classroom is also provided with the book. Access to extra online worksheets, educational activities, and scenario-based movies to practice the documentation process is also provided with the book.
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