The OTA’s Guide to Documentation: Writing SOAP Notes
by Marie Morreale, Sherry Borcherding
This guide equips occupational therapy assistants with the tools to write clear, effective SOAP notes. Covering the essentials of Subjective, Objective, Assessment, and Plan sections, it ensures accurate documentation for better patient outcomes and professional compliance. Authored by experts Marie Morreale and Sherry Borcherding, it's a vital resource for clinical practice.
About This Book
The OTA’s Guide to Documentation: Writing SOAP Notes offers essential guidance for occupational therapy assistants on creating professional documentation. Authored by Marie Morreale and Sherry Borcherding, it focuses on the SOAP format—Subjective, Objective, Assessment, and Plan—to support effective patient care records.
This resource emphasizes clarity and precision in writing, helping OTAs meet documentation standards in various healthcare settings. It covers best practices for capturing relevant information without unnecessary details.
Ideal for students and practicing professionals, the guide enhances skills in articulating therapy sessions and progress notes. It promotes consistent, defensible documentation that aligns with occupational therapy principles.
Through structured examples and tips, readers learn to integrate SOAP notes into daily workflows, improving communication among healthcare teams.
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