The best-selling, newly updated occupational therapy textbook Documentation Manual for Occupational Therapy, Fifth Edition, is made for students and early-career practitioners learning the critical skill of documentation.
The workbook format offers students ample opportunities to practice writing occupation-based problem statements and goals, intervention plans, SOAP notes, and other forms of documentation. The Fifth Edition has also been updated to reflect changes in the American Occupational Therapy Association’s Occupational Therapy Practice Framework: Domain and Process, Fourth Edition.
What’s included in Documentation Manual for Occupational Therapy:
• Numerous worksheets for students to practice individual skills with suggested answers provided in the Appendix
• Updated information on coding, billing, and reimbursement to reflect recent Medicare changes, particularly in post–acute care settings
• Examples from a variety of contemporary occupational therapy practice settings
Included with the text are online supplemental materials for faculty use in the classroom. Instructors in educational settings can visit the site for an Instructor’s Manual with resources to develop an entire course on professional documentation or to use the textbook across several courses.
One of the most critical skills that occupational therapy practitioners must learn is effective documentation to guide client care, communicate with colleagues, and maximize reimbursement. The newly updated and expanded Documentation Manual for Occupational Therapy, Fifth Edition, will help students master their documentation skills before they ever step foot into practice.
Dedication
Acknowledgments
About the Author
Chapter 1 Documenting the Occupational Therapy Process
Chapter 2 The Health Record
Chapter 3 Reimbursement, Coding, and Billing
Chapter 4 Legal, Regulatory, and Ethical Considerations
Chapter 5 General Guidelines for Documentation
Chapter 6 Writing Occupation-Based Problem Statements
Chapter 7 Writing Measurable Occupation-Based Goals and Objectives
Chapter 8 Writing the S—Subjective
Chapter 9 Writing the O—Objective
Chapter 10 Writing the A—Assessment
Chapter 11 Writing the P—Plan
Chapter 12 Intervention Planning
Chapter 13 Documentation in Different Practice Settings
Chapter 14 Electronic Documentation
Chapter 15 Examples of Notes Across Various Stages of Occupational Therapy Service Delivery
Appendix Suggestions for Completing the Worksheets
Index
Biography
Crystal A. Gateley, PhD, OTR/L is Associate Chair and Teaching Professor at the University of Missouri, Department of Occupational Therapy, where she has been a full-time faculty member since 2009. She serves as Program Director for the Entry-Level Occupational Therapy Doctorate (OTD) program, providing oversight of curriculum revision and accreditation compliance. She also assists with new program development and the myriad of issues faced by a growing department. In addition to her administrative responsibilities, she teaches a variety of courses across the curriculum including Clinical Reasoning and Documentation, Foundations and Theory in Occupational Therapy, Conditions in Occupational Therapy, Psychosocial Aspects of Occupational Therapy, Emerging Trends in Occupational Therapy, Professional Seminar, Capstone Mentor Hour I and II, and Leadership, Management, and Policy. She also has taught interdisciplinary courses including Clinical Pathophysiology and Introduction to the Health Professions. Crystal graduated Summa Cum Laude from the University of Missouri in 1995 with a Bachelor of Health Science in Occupational Therapy. She went on to complete a master’s (2003) and doctorate (2015) in Educational Leadership and Policy Analysis with an Emphasis in Higher Education and Administration, also from the University of Missouri. Crystal has worked in a variety of occupational therapy practice settings throughout her career, including acute care, inpatient and outpatient rehabilitation, skilled nursing, home health, early intervention, outpatient pediatrics, public schools, and community programs for adults with developmental disabilities. She still provides occasional occupational therapy coverage at Boone Health in Columbia, Missouri, on weekends and holidays, and her experiences there with patients and interprofessional colleagues inform her teaching as she passes along insights from contemporary occupational therapy practice to her students. Beyond her love for college teaching and occupational therapy practice, Crystal enjoys spending time with friends and family in outdoor activities including hiking, camping, fishing, canoeing, and rafting along various Missouri rivers. She is an avid football fan, and she is still basking in the glory of the Kansas City Chiefs’ Super Bowl victories in 2020 and 2023! She currently lives in rural Holts Summit, Missouri, with her husband Curt, her parents, and her two cats, Cora and Loki. Crystal treasures the occasional phone calls and visits from her two daughters, Katrina and Lauren, who are pursuing their dreams in Connecticut and Tennessee.
