Documentation Manual for Occupational Therapy

Description

Documentation Manual for Occupational Therapy (5th Edition) by Crystal Gateley is a comprehensive, up-to-date resource designed to teach occupational therapy (OT) students and practitioners how to effectively and professionally document their clinical services. Aligned with current AOTA and reimbursement standards, this manual simplifies the documentation process while reinforcing the critical role it plays in patient care, legal compliance, and professional accountability.

This 5th edition includes updates that reflect the latest practice models, terminology, and healthcare regulations, including changes related to Medicare, Medicaid, and third-party reimbursement. Whether you’re in school, on fieldwork, or practicing in a clinical setting, this guide provides clear, practical examples and templates to help you write accurate and efficient documentation across a variety of OT settings.

Key Features:

• Step-by-step instruction on writing SOAP notes, evaluations, progress reports, discharge summaries, and more

• Aligned with OTPF-4 and ICD-10 coding standards

• Covers documentation for acute care, rehabilitation, mental health, pediatrics, and community-based practice

• Includes sample notes, checklists, and common mistakes to avoid

• Emphasizes legal, ethical, and reimbursement considerations

This manual supports both academic learning and real-world application, making it a go-to reference for students, new graduates, and experienced practitioners seeking clarity and consistency in their documentation practices.

Perfect For:

• Occupational therapy students in undergraduate or graduate programs

• Fieldwork educators and new practitioners needing documentation guidance

• Academic instructors looking for a comprehensive teaching resource

• Clinicians in diverse practice areas who need compliant and effective documentation tools

With its easy-to-follow layout, evidence-based guidelines, and professional insights, the Documentation Manual for Occupational Therapy (5th Edition) ensures your notes not only meet standards—but elevate your OT practice.