Effective Occupational Therapy Documentation

Brittany Ferri

Series: Physical Medicine and Rehabilitation
BISAC: MED061000



Volume 10

Issue 1

Volume 2

Volume 3

Special issue: Resilience in breaking the cycle of children’s environmental health disparities
Edited by I Leslie Rubin, Robert J Geller, Abby Mutic, Benjamin A Gitterman, Nathan Mutic, Wayne Garfinkel, Claire D Coles, Kurt Martinuzzi, and Joav Merrick


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Patient care is the cornerstone of occupational therapy, but it does not exist in isolation. Documentation is an important counterpart, which ensures accurate reimbursement, treatment, and justification for care. However, students often struggle with documentation courses and professors similarly have difficulty teaching such an extensive topic.

Due to stark differences between occupational therapy practice areas and even facilities of the same type, therapists are left to fill in the gaps and teach themselves documentation skills. Therapists are often without a reliable, hands-on tool to gain adequate documentation skills, both in school and in the clinic.

Effective Occupational Therapy Documentation serves as a go-to guide for learning and practicing basic therapy documentation. This useful reference tool provides the structure for therapy notes in every setting, along with rationale for how other healthcare disciplines fit into therapy documentation.
(Imprint: Nova Medicine and Health)

Chapter 1. Medical Necessity

Chapter 2. Note Writing

Chapter 3. What to Avoid

Chapter 4. Scope of Practice

Chapter 5 . Electronic Medical Records (EMRs)

Chapter 6. Conclusion

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