Documentation Manual for Occupational Therapy

Crystal A. Gateley, PhD, OTR/L is Associate Chair and Associate Teaching Professor at University of Missouri in Columbia, where she has taught since 2009. She teaches a variety of courses across the curriculum including Foundations & Theory in OT, Clinical Pathophysiology, Human Development & Occupations I and II, Level I Fieldwork, and Clinical Reasoning & Documentation. Crystal graduated Summa Cum Laude from University of Missouri with a BHS in Occupational Therapy and went on to complete a master’s and doctorate in Educational Leadership and Policy Analysis (ELPA), also from University of Missouri. Crystal has worked in a variety of occupational therapy practice settings, including acute care, inpatient and outpatient rehabilitation, skilled nursing, home health, outpatient pediatrics, public schools, and sheltered workshops. Besides teaching, Crystal enjoys attending her daughters’ extracurricular events, particularly Southern Boone Lady Eagles soccer and basketball, and frequently volunteers her time to support school and community organizations. She also loves camping, fishing, canoeing, and boating with family and friends.   Sherry Borcherding, MA, OTR/L is retired from the faculty of University of Missouri, where she taught for 15 years. During the time she was on 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. Two of her courses were designated as campus writing courses and one was credentialed for computer and information proficiency. As a part of the fieldwork and documentation courses, she filmed simulated occupational therapy interventions for student use in class. Twelve of those “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. Following 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; and Director of Rehabilitation Services at Transitional Housing Agency, Columbia, Missouri. She has also planned, designed and directed occupational therapy programs at Capital Regional 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 at the techniques level through Upledger Institute, Palm Beach Gardens, Florida and is attuned as a Reiki master. 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. She volunteers with the Community Emergency Response Team doing logistics.    

Dedication
Acknowledgments
About the Authors
 
Chapter 1           Documenting the Occupational Therapy Process
Chapter 2           The Health Record
Chapter 3           Reimbursement, Legal, and Ethical Considerations
Chapter 4           General Guidelines for Documentation
Chapter 5           Writing Occupation-Based Problem Statements
Chapter 6           Writing Measurable Occupation-Based Goals and Objectives
Chapter 7           Writing the “S”—Subjective
Chapter 8           Writing the “O”—Objective
Chapter 9           Writing the “A”—Assessment
Chapter 10        Writing the “P”—Plan
Chapter 11        Making Good Notes Even Better
Chapter 12        Intervention Planning
Chapter 13        Documenting Different Stages of Service Delivery
Chapter 14        Documentation in Different Practice Settings
Chapter 15        Electronic Documentation
Chapter 16        Examples of Different Kinds of Notes
 
Appendix: Suggestions for Completing the Worksheets
Index