The OTA's Guide to Documentation Writing SOAP Notes

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.

Dedication  
Acknowledgments  
About the Authors  

Chapter 1 Documenting the Occupational Therapy Process  
Chapter 2 The Health Record  
Chapter 3 Billing and Reimbursement  
Chapter 4 Using Medical Terminology  
Chapter 5 Avoiding Common Documentation Mistakes  
Chapter 6 Writing the “S”—Subjective  
Chapter 7 Writing the “O”—Objective  
Chapter 8 Tips for Writing a Better “O”  
Chapter 9 Writing the “A”—Assessment  
Chapter 10 Writing the “P”—Plan  
Chapter 11 Documenting Special Situations  
Chapter 12 Improving Observation Skills and Refining Your Note  
Chapter 13 Making Good Notes Even Better  
Chapter 14 Evaluation and Intervention Planning  
Chapter 15 Goals and Interventions  
Chapter 16 Documenting Different Stages of Treatment  
Chapter 17 Documentation in Different Practice Settings  
Chapter 18 Examples of Different Kinds of Notes  References  

Appendix: Suggestions for Completing the Worksheets  
Index