The OTA's Guide to Writing SOAP Notes - Sherry Borcherding, Marie J. Morreale. Fusion Web Clinic Therapy Documentation Software. Fieldworkmanual.pdf. Quick Notes OT's SOAP. Untitled. Soap Note Writing Documentation is often a difficult task for a student to grasp.
Unfortunately, the insurance companies rarely come see what therapy is doing. They base their decision to pay for the services strictly on the documentation. Think of your documentation as the paper trail. It must tell this child's story to someone who is not in the room. Untitled. Assessment and Therapy 1 SOAP Note writing- examples Writing SOAP notes is a skill which you can learn.
I recommend you study from the book entitled Documentation Manual for Writing SOAP Notes in Occupational Therapy by Sherry Borcherding. Below are some examples from other students as a guide. They are not all perfect, but provide some good examples for you to learn from. 40 Documentation Terms for Pediatric Therapists.