Documentation Manual for Writing SOAP Notes in Occupational Therapy

One of the most critical skills today’s occupational therapists will need to learn and master is documentation. The most successful workbook on the market to educate students and keep professionals sharp is Documentation Manual for Writing SOAP Notes in Occupational Therapy―now available in an improved and revised second edition.



This workbook successfully uses a “how to” approach to explain the critical skill of documentation. By concentrating on the instruction of one essential skill and not diverging into other related areas, this new edition allows occupational therapists to focus completely on writing SOAP notes.



Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition is designed to break down the task of SOAP documentation into manageable units of skill sets. Sherry Borcherding has identified the concepts that are the most difficult to grasp and has incorporated new worksheets to help better understand these important terms.



The new edition of this indispensable workbook provides a better representation of the major practice settings in which occupational therapists are employed, including mental health and pediatric settings. Complementary therapies have also been included with examples of documentation for two common techniques, CranioSacral Therapy and Tai Chi.



New worksheets, revised chapters, and clinical examples ensure that Documentation Manual for Writing SOAP Notes in Occupational Therapy, Second Edition will be the only resource needed by occupational therapy students and professionals.


Features of the Second Edition include:

Documentation skills based on the concepts found in the Occupational Therapy Practice Framework. An explanation of The AOTA’s Guidelines for Documentation of Occupational Therapy Practice, including examples. A brief discussion of HIPAA, billing codes, and their importance in reimbursement. Detachable worksheets that walk students through the skills needed for successful documentation in the client’s health record. A detachable checklist to be used as a quick reference when evaluating your SOAP Note to ensure that all of the essential elements are included. Clinical examples that show a variety of successful wordings for each concept. Reorganized chapters that offer a user-friendly format and logical presentation of material.

Sherry Borcherding, MA, OTR/L currently serves as a faculty member at University of Missouri–Columbia, a Carnegie Research Extensive University, where she has taught since 1992. She teaches disability awareness, complementary therapy, and a three-semester fieldwork sequence designed to develop critical thinking, clinical reasoning, and documentation skills. She has also taught clinical ethics, frames of reference, psychopathology, loss and disability, long-term care, and wellness. Two of her courses are designated as campus writing courses and one is credentialed for computer and information proficiency. Sherry is frequently invited to present on collaborative learning, peer review, and educational technology.

Sherry graduated with honors from Texas Woman's University 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 in 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, Director of Occupational Therapy at Mid-Missouri Mental Health Center, and Director of Rehabilitation Services at Transitional Housing Agency. She has also planned, designed, and directed occupational therapy programs at Capital Regional Medical Center in Jefferson City, MO and at Charter Behavioral Health Center in Columbia, MO.

Besides teaching, Sherry consults on quality assurance issues for local behavioral health centers and has a private practice devoted to complementary and alternative therapies. She is certified in CranioSacral Therapy at the techniques level through Upledger Institute and is attuned as a Reiki master. For leisure, Sherry enjoys folk dance, music, and all kinds of three-dimensional art. Her pottery has appeared in several local shows over the past two years.

Marie J. Morreale, OTR/L, CHT has been teaching in the Occupational Therapy Assistant Program at Rockland Community College since 1998. She is part of the adjunct faculty and currently teaches Professional Issues and Documentation, OT Skills, Geriatric Principles, and Advanced OT Skills. Besides making significant contributions to curriculum development, Marie has served as interim program coordinator and has also taught several other courses in the OTA program, including OT Therapeutic Activities and Advanced Therapeutic Activities.

Since graduating Summa Cum Laude from Quinnipiac College (now Quinnipiac University), Marie 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. She also served for several years on a home health Professional Advisory Committee (consulting on quality assurance issues), and has been a Certified Hand Therapist since 1993. In addition, Marie is the author of several online continuing education courses and was selected for Who’s Who Among America’s Teachers in 2003-2004.

When not teaching, Marie is an active member of her church community where she voluntarily chairs various fundraising events and community activities. In addition, Marie is an avid reader and she also enjoys all kinds of domestic and international travel.