Clear, accurate documentation is a crucial skill for occupational therapists, ensuring continuity of care, legal compliance, and effective communication. This book introduces the foundations of clinical writing, with a focus on structured assessment reporting, intervention planning, and outcome documentation. It presents commonly used formats such as SOAP notes and DAP notes, alongside guidelines for electronic health records. The text covers the importance of clarity, objectivity, and ethical considerations in professional writing. Case-based examples illustrate how to convey client progress, justify clinical decisions, and meet billing or regulatory requirements. The content supports both students and practitioners in developing professional documentation habits.
Saige Parker is an occupational therapist and academic specializing in clinical documentation, professional communication, and outcome-based reporting. Based in Australia, she teaches occupational therapy students how to articulate intervention plans, track progress, and communicate effectively with multidisciplinary teams. Saige has published on best practices in health documentation and maintains a strong emphasis on accuracy, clarity, and ethical standards. Her work enhances the professional voice of occupational therapists in legal, clinical, and educational contexts.