Documentation Manual for Occupational Therapy

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.

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