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OTA's Guide to Documentation


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Table of Contents

AcknowledgmentsAbout the AuthorsChapter 1 Documenting the Occupational Therapy ProcessChapter 2 The Health RecordChapter 3 Billing and ReimbursementChapter 4 Using Professional TerminologyChapter 5 Avoiding Common Documentation MistakesChapter 6 Writing the "S"-SubjectiveChapter 7 Writing the "O"-ObjectiveChapter 8 Tips for Writing a Better "O"Chapter 9 Writing the "A"-AssessmentChapter 10 Writing the "P"-PlanChapter 11 Documenting Special SituationsChapter 12 Improving Observation Skills and Refining Your NoteChapter 13 Making Good Notes Even BetterChapter 14 Evaluation and Intervention PlanningChapter 15 Goals and InterventionsChapter 16 Documenting Different Stages of InterventionChapter 17 Documentation in Different Practice SettingsChapter 18 Examples of Different Kinds of NotesAppendix: Suggestions for Completing the WorksheetsIndex

About the Author

Marie J. Morreale, OTR/L taught occupational therapy assistant (OTA) students for 17 years at Rockland Community College, State University of New York. As an adjunct faculty member, her various courses included: Professional Issues and Documentation; Geriatric Principles; OT Skills; Advanced OT Skills; Therapeutic Activities; and Advanced Therapeutic Activities. Marie contributed significantly to curriculum development and served briefly as interim coordinator of the OTA Program.

Marie graduated Summa Cum Laude from Quinnipiac College (now Quinnipiac University) in Hamden, Connecticut, and has clinical experience in a variety of OT practice settings including: inpatient and outpatient rehabilitation, long-term care, adult day care, home health, cognitive rehabilitation, and hand therapy. She maintained certification in hand therapy for over 20 years and also served several years on a home health Professional Advisory Committee, consulting on quality assurance issues. Marie enjoys professional writing and, in addition to co-authoring the prior two editions of this documentation manual, has published several other occupational therapy texts: The Occupational Therapist's Workbook for Ensuring Clinical Competence and Developing Clinical Competence: A Workbook for the OTA. Additional published works include a chapter on documentation for The Occupational Therapy Manager, Fifth Edition, several OT articles and web-based continuing education courses. She is also a test item writer for the American Occupational Therapy Association continuing education products. In her spare time, Marie is active in her church community and has a passion for travel. Sherry Borcherding, MA, OTR/L is retired from the faculty of the University of Missouri-Columbia, where she taught for 15 years. During the time she was on the faculty, she taught disability awareness, complementary therapy, clinical ethics, frames of reference, psychopathology, loss and disability, long term care, wellness, and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. As a part of the fieldwork and documentation courses, she filmed simulated occupational therapy interventions for student use in class. Three of these "movies" are available on www.efacultylounge.com with this edition of the book. Sherry graduated with honors from Texas Woman's University, Denton, Texas with a BS in occupational therapy and went on to complete her master's in special education with special faculty commendation at George Peabody College, Nashville, Tennessee. Along with her staff positions in rehabilitation, home health, and pediatrics, she assumed a number of management roles, including Chief Occupational Therapist at East Texas Treatment Center, Kilgore, Texas; Director of Occupational Therapy at Mid-Missouri Mental Health Center, Columbia, Missouri; and Director of Rehabilitation Services at Transitional Housing Services, Columbia, Missouri. She has planned, developed, and directed occupational therapy programs at Capitol Region Medical Center, Jefferson City, Missouri and at Charter Behavioral Health Center, Columbia, Missouri. Sherry is a lifelong learner. Since her retirement, she has further expanded her private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy through Upledger Institute, Palm Beach Gardens, Florida, and is attuned as a Reiki master. She is currently learning Eden Energy Medicine. For leisure, Sherry enjoys music, English country dance, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past several years. For 10 years, she volunteered with the Community Emergency Response team doing logistics.

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