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  • Occupational Therapy
  • Occupational Therapy Assistants
Hours: 2 Contact Hours
Author(s): Jessica J. Bolduc, DrOT, MSOTR/L
Peer Reviewer(s): Nancy MacRae, MS, OTR/L, FAOTA
Item#: I6371
Contents: 1 Course Book (54 pages)
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Documentation in Occupational Therapy Practice

Price $24.95
Item # I6371
When available, the Online Course format is included with the hard copy, eBook, or audio book formats!

Release Date: March 4, 2016

Expiration Date: March 4, 2019

Occupational therapy practitioners typically complete some type of documentation required by their place of employment or practice area. Proper documentation provides suitable records of client contact, evaluation, and interventions that offer client information from an occupational therapy perspective, articulate the rationale for occupational therapy services, and provide a chronological record of the client’s status. Additionally, these records are often required as part of payment for service and provide a legal record of services rendered.

The Occupational Therapy Practice Framework, 3rd edition, provides practitioners with documentation language that accurately describes the nature of occupational therapy services provided to clients. Using this approved language strengthens documentation and enables others outside of occupational therapy practice to better understand the role of occupational therapy. However, most seasoned practitioners have not had formal training in using the Occupational Therapy Practice Framework language. This basic-level course provides an introduction to this language and fosters its use for effective clinical documentation in a variety of occupational therapy practice settings.

Upon completing this course, occupational therapy practitioners will be able to describe and use effective language and strategies for documentation of evaluation and treatment, as well as for writing discharge reports, in a variety of settings. Furthermore, practitioners will be prepared to explain and use more effective and efficient documentation in many areas of practice.


AOTA Content Focus - Occupational Therapy Process; evaluation, intervention. Professional Issues; administration/managment, OT Education



Course Objectives

  • Describe effective strategies for occupational therapy documentation
  • Define the occupational therapy practitioner’s ethical and legal responsibility in the context of documentation
  • Identify the types of language used in occupational therapy documentation
  • Differentiate among the various categories of documentation used in practice
  • Identify the documentation used in different occupational therapy practice settings


Jessica J. Bolduc, DrOT, MSOTR/L, received her master’s degree from the University of New England in 2005 and her doctorate in 2013 from Nova Southeastern University. Her clinical experience spans the continuum of care, including acute care, inpatient rehabilitation, outpatient rehabilitation, skilled nursing, and home health. Dr. Bolduc has served as adjunct professor in the occupational therapy department at the University of New England and the University of Southern Maine, where she taught courses on physical dysfunction. She served as vice president of the Vermont Occupational Therapy Association for two years and as president for three years. She is currently active with the Maine Occupational Therapy Association. Dr. Bolduc was selected to join the first cohort of the Emerging Leaders Development Program of the American Occupational Therapy Association (AOTA) and was subsequently appointed to AOTA’s Emerging Leaders Development Committee and Volunteer Leadership Development Committee. She has received two service commendations from AOTA, as well as the Young Alumni Award from the University of New England and the Alpha Eta Richard E. Davis Service Award from Nova Southeastern University. She was inducted into the Nu Sigma Upsilon Chapter of the Alpha Eta Society for scholarly accomplishments at Nova Southeastern University. Dr. Bolduc is licensed in occupational therapy in four states and is a certified clinical fieldwork educator. She has published in OT Practice, The Internet Journal of Allied Health, Sciences and Practice, and has written textbook chapters in Gerontology for the Health Care Professional and Occupational Therapy Essentials for Clinical Competence. She has presented at national and state occupational therapy conferences. In addition to her ongoing work as a staff occupational therapist, Dr. Bolduc serves as the occupational therapy planner for Western Schools, an AOTA-approved provider of continuing education.


Nancy MacRae, MS, OTR/L, FAOTA, is an associate professor in the Occupational Therapy Department at the University of New England in Biddeford, Maine, where she has taught and served in numerous leadership roles since 1995. Immediately prior to entering academia, Ms. MacRae was Chief of Occupational Therapy and Program Services Director of the Aging Cluster at the Pineland Center in Pownal, Maine. She has served as a staff occupational therapist in a variety of practice settings during her career, working across the lifespan with the developmentally disabled population. Ms. MacRae received her master of science degree in adult education from the University of Southern Maine in 1989 and her bachelor of science degree in occupational therapy from the University of New Hampshire in 1966. She has published extensively on topics such as clinical competence, occupational therapy documentation, sexuality and aging, and interprofessional education. She is a co-editor of Occupational Therapy Essentials for Clinical Competence (2nd ed.) and serves on the editorial board of the journal WORK. Most recently, Ms. MacRae has presented both nationally and internationally on aging and disabilities, fall prevention, and sexuality and aging. In July of 2015, Ms. MacRae became a founding member of the American Occupational Therapy Foundation’s Leaders and Legacies Society, reflecting her sustained and distinguished service to the profession of occupational therapy.

  • Courses must be completed on or before the expiration date noted in the course description above.
  • You must score 75% or higher on the final exam and complete the course evaluation to pass this course and receive a certificate of completion
  • Through our review processes, Western Schools ensures that the course content is presented in a balanced, unbiased manner and is free from commercial influence. It is Western Schools’ policy not to accept commercial support
  • All persons involved in the planning and development of this course have disclosed no relevant financial relationships or other conflicts of interest related to the course content
  • There are no prerequisites for this course
  • Ms. MacRae has disclosed that she receives royalties from Slack, Inc., in connection with her role as a co-editor of Occupational Therapy Essentials for Clinical Competence (2nd ed.). She has agreed to present content that represents current, evidence-based practice, without bias.