Abstract
This is a practical book on documentation for occupational therapists. Although it is based on the American Occupational Therapy Association’s Guidelines for Documentation of Occupational Therapy, it is still very relevant and useful to Canadian occupational therapists. Each section presents theory followed by several examples. At the end of each chapter, there are some additional worksheets for readers to complete to assess their level of comprehension.
In this new edition, there is an additional focus on all areas of documentation, not just SOAP notes, including chapter 4’s general guidelines for documentation. According to the authors, “the most significant change in this edition is the introduction of a new format called COAST method for writing goals and objectives”. This is an interesting addition. It is a similar method to the ABCD proposed by Kettenbach (1995), but there is the addition of some elements of the SMART method as well. This edition also comes with an instructor manual (not available for review) that includes suggestions for assignments and quizzes and access to videos that may be used for developing documentation skills. As in previous editions, there are several chapters on how to write SOAP notes, which is slightly different than the method proposed by Kettenbach. The main difference lies in the way of writing the P section.
This book was primarily designed to help with one important aspect of clinical instruction: teaching documentation. Thus, it is mostly for educators and students but can be a valuable addition to a department receiving students on placement or for therapists wanting to improve their documentation skills.