The OTA’s Guide to Documentation 5th Edition

The OTA’s Guide to Documentation, 5th Edition by Marie Morreale is the essential handbook for occupational therapy assistants who want clear, practical guidance on accurate, compliant clinical documentation. Updated for today’s healthcare environment, this edition translates complex documentation standards into simple, usable steps that support better patient care and smoother workflows.

Inside, readers will find straightforward explanations of documentation principles, legal and ethical considerations, and reimbursement essentials—presented with real-world examples, sample notes, and checklists that make learning efficient. Whether writing SOAP notes, progress reports, or discharge summaries, OTAs will gain confidence in crafting concise, defensible records that meet regulatory and facility requirements. The guide also addresses documentation best practices for electronic health records (EHRs), interdisciplinary communication, and outcome tracking.

Designed for students, fieldwork candidates, and practicing OTAs in the U.S. and beyond, this resource helps bridge classroom knowledge and everyday clinical demands. Clear language and practical tips speed documentation, reduce errors, and enhance professional communication with supervisors and interdisciplinary teams. The result: improved patient continuity, stronger audit readiness, and greater job confidence.

If you’re aiming to sharpen your documentation skills, ensure compliance, and streamline your clinical notes, The OTA’s Guide to Documentation, 5th Edition by Marie Morreale is a must-have reference. Purchase your copy today and build the documentation competence that employers and patients rely on.

Note: eBooks do not include supplementary materials such as CDs, access codes, etc.