The OTA's Guide to Documentation: Writing SOAP Notes

With the current changes in health care, proper documentation of client care is essential in meeting the legal, ethical, and professional standards for reimbursement of services. Written specifically for occupational therapy assistants, The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition contains the step-by-step instruction needed to learn the documentation required for occupational therapy clinical practice and reimbursement.

Written in an easy-to-read format, this Third Edition by Marie J. Morreale and Sherry Borcherding allows occupational therapy assistants to learn the purpose and standards of documentation throughout all stages of the occupational therapy process and in a variety of practice settings.

New features in the Third Edition:

• Incorporation of the Occupational Therapy Practice Framework: Domain and Process, Second Edition along with other updated American Occupational Therapy Association documents
• Electronic documentation information
• Information on International Classification of Functioning, Disability, and Health language
• Information on narrative notes with examples
• A new chapter on “Billing and Reimbursement” with a focus on funding sources and requirements
• More information and examples for pediatric, school-based, and mental health practice settings
• Information on quality measures
• New worksheets for developing occupational therapy goals
• Additional worksheets on documentation mistakes and basics of documentation
• A new method of goal writing (COAST)
• Lists of professional language

This text teaches the SOAP notes format reimbursable by Medicare Part B and other third party payers. Other topics include a review of spelling and grammar, an overview of the initial evaluation process delineating the roles of the occupational therapist and the occupational therapy assistant, tips for clinical reasoning, and guidelines for selecting appropriate interventions.

The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition offers both the necessary instruction and multiple opportunities to practice. Templates allow beginning students to practice formatting SOAP notes, and a detachable summary sheet can be pulled out and carried to clinical sites as a reminder of the necessary contents for a SOAP note. Multiple worksheets are provided for practice in developing observation skills, clinical reasoning, documentation skills, and a repertoire of professional language. All worksheets in this Third Edition are available online, with answers included to enable independent study. Occupational therapy assistant students and faculty as well as practicing occupational therapy assistants and rehabilitation professionals will appreciate this valuable text.

As a bonus, when you purchase a new copy of The OTA’s Guide to Documentation: Writing SOAP Notes, Third Edition, you will receive access to scenario-based videos to practice the documentation process.

Marie J. Morreale, OTR/L, CHT is an adjunct faculty member at Rockland Community College, State University of New York. She has been teaching students in the Occupational Therapy Assistant Program there since 1998. Marie’s courses include Professional Issues and Documentation, OT Skills, Geriatric Principles, and Advanced OT Skills. Early in her teaching career, she taught several other courses in the OTA Program such as Therapeutic Activities and Advanced Therapeutic Activities. Besides making significant contributions to curriculum development, Marie also served as interim coordinator of the OTA Program.     

Marie graduated summa cum laude from Quinnipiac College in Hamden, CT (now Quinnipiac University) with a BS in occupational therapy. She has worked in a variety of OT practice settings including inpatient and outpatient rehabilitation, long-term care, adult day care, home health, cognitive rehabilitation, and hand therapy. Marie has been a Certified Hand Therapist since 1993 and also served several years on a home health Professional Advisory Committee, consulting on quality assurance issues. In addition to co-writing the prior edition of this book, Marie wrote a chapter on documentation for The Occupational Therapy Manager, 5th Edition and has published several OT articles. She is also the author of two online continuing education courses. Marie was selected for Who’s Who Among America’s Teachers and, when not teaching, is active in her church community and enjoys anything travel-related.      

Sherry Borcherding, MA, OTR/L recently retired from the faculty of University of Missouri-Columbia, where she taught for 15 years. During the time she was on the faculty, she taught disability awareness; complementary therapies; clinical ethics; frames of reference; psychopathology; loss and disability; long-term care; wellness; and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. Two of her courses were designated as campus writing courses, and one was credentialed for computer and information proficiency. As a part of the fieldwork and documentation courses, she filmed simulated occupational therapy interventions for student use in class. Three of these “movies” are available on www.efacultylounge.com with this edition of the book.   

Sherry graduated with honors from Texas Woman’s University, Denton, TX with a BS in occupational therapy, and went on to complete her master’s in special education with special faculty commendation at George Peabody College, Nashville, TN. Following her staff positions in rehabilitation, home health, and pediatrics, she assumed a number of management roles, including Chief Occupational Therapist at East Texas Treatment Center, Kilgore, TX, and at Mid-Missouri Mental Health Center, Columbia, MO, as well as Director of Rehabilitation Services at Transitional Housing Agency, Columbia, MO. She also planned, designed, and directed occupational therapy programs at Capitol Regional Medical Center, Jefferson City, MO, and at Charter Behavioral Health Center, Columbia, MO.        

Sherry is a lifelong learner. Since her retirement, she has further expanded her private practice devoted to complementary and alternative therapies. She is certified in craniosacral therapy at the techniques level through Upledger Institute, Palm Beach Gardens, FL, and is attuned as a Reiki master. She volunteers with the Community Emergency Response Team affiliated with the fire department, and with the Medical Reserve Corps affiliated with the public health department. For leisure, Sherry enjoys music, dance, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past few years.