Documentation Manual for Occupational Therapy

• Main Authors: Gateley, Crystal A. (Author), Borcherding, Sherry (Author)
• Format: Book
• Language: English
• Published: Thorofare SLACK incorporated 2024
• Edition: FIFTH EDITION
• Subjects: Medical Records; Medical protocols; Forms and Records Control; Occupational Therapy > methods
• Online Access: Click Here to View Status and Holdings.
• Physical Description: x, 268 pages illustrations 28 cm
• Bibliography: Includes bibliographical references (pages 237) and index
• ISBN: 9781638220602

"Occupational therapy practitioners use different formats for documentation depending on their practice settings. This manual introduces specific formats for writing occupation-based problem statements and goals. In addition, the manual presents a systematic approach to one form of documentation: the SOAP note. SOAP is an acronym for the four parts of an entry into a health record. The letters stand for Subjective, Objective, Assessment, and Plan. Although not all practice settings use the SOAP note format, the professional reasoning skills underlying SOAP note documentation can be adapted to nearly any occupational therapy practice setting. This book presents essential documentation skills that all occupational therapy practitioners will find critical for assessing, treating, and offering the best evidence available for their clients"--