Contents
Dedication
Acknowledgments
About the Author
Chapter 1 Documenting the Occupational Therapy Process
Chapter 2 The Health Record
Chapter 3 Billing and Reimbursement
Chapter 4 Using Professional Terminology
Chapter 5 Avoiding Common Documentation Mistakes
Chapter 6 Writing the S—Subjective
Chapter 7 Writing the O—Objective
Chapter 8 Tips for Writing a Better O
Chapter 9 Writing the A—Assessment
Chapter 10 Writing the P—Plan
Chapter 11 Documenting Special Situations
Chapter 12 Improving Observation Skills and Refining Your Note
Chapter 13 Making Good Notes Even Better
Chapter 14 Evaluation and Intervention Planning
Chapter 15 Goals and Interventions
Chapter 16 Documenting Different Stages of Intervention
Chapter 17 Documentation in Different Practice Settings
Chapter 18 Examples of Different Kinds of Notes
Appendix: Suggestions for Completing the Worksheets
Index
Biography
Marie J. Morreale, OTR, graduated Summa Cum Laude from Quinnipiac College (now Quinnipiac University) with a BS in occupational therapy. Throughout her professional career, Marie worked in a variety of practice settings, including inpatient and outpatient rehabilitation, cognitive rehabilitation, adult day care, skilled nursing facilities, home health, and hand therapy. She held the designation of Certified Hand Therapist for 25 years and served several years on a home health professional advisory committee, consulting on quality assurance issues. For 17 years, Marie taught OTA students at Rockland Community College, State University of New York in Suffern as an adjunct faculty member. She taught a variety of courses there, which included Professional Issues and Documentation, Geriatric Principles, Occupational Therapy Skills, Advanced Occupational Therapy Skills, Therapeutic Activities, and Advanced Therapeutic Activities, in addition to serving brief ly as interim coordinator of the OTA Program. Marie co-authored the second, third, and fourth editions of The OTA’s Guide to Documentation: Writing SOAP Notes. She also created the first and second editions of Developing Clinical Competence: A Workbook for the OTA and co-authored The Occupational Therapist’s Workbook for Ensuring Clinical Competence. In addition, she wrote a chapter on documentation for The Occupational Therapy Manager, Fifth Edition, and published several occupational therapy articles. For the past several years Marie has been a test item writer for American Occupational Therapy Association continuing education products. She is active in her condo community and enjoys anything travel related.
