Documenting Occupational Therapy Practice / Edition 1

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Overview

A comprehensive guide to creating effective documentation in occupational therapy.

Documenting Occupational Therapy Practice, 3/e is the most comprehensive text on occupational therapy documentation currently on the market, covering general documentation principles, clinical documentation, electronic documentation, school system documentation, and documentation of administrative tasks. More than just a how-to manual, the text explores important ethical, legal, and language issues related to documentation in addition to presenting step-by-step strategies for creating successful SOAP notes, communications, and documentation. The Third Edition has been fully updated to reflect current AOTA official documents and new electronic documentation tools, and has been reorganized to improve readability. Effective review tools help readers truly master documentation techniques and strategies, while the text’s accompanying website provides additional learning resources that can be accessed on the go.

Teaching and Learning Experience

This text offers a comprehensive guide to creating effective documentation for occupational therapy. It provides:

  • Comprehensive coverage of all areas of practice: Chapters examine the underlying concepts of good documentation in clinical, school, and administrative settings.
  • Practical techniques and strategies that prepare students for the workplace: Chapters present clear, effective strategies for drafting documentation and communication that can be directly applied in professional settings.
  • Exploration of ethical and legal issues: Discussions help students understand how documentation affects others and provide problem-solving strategies for addressing legal and ethical issues.
  • Coverage of electronic documentation: Screenshots and discussion of electronic health record (EHR) systems familiarize students with current documentation technologies.
  • Effective learning tools: Review exercises and numerous reference tools help students truly master text material.
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Product Details

  • ISBN-13: 9780130452146
  • Publisher: Prentice Hall
  • Publication date: 2/27/2004
  • Edition description: Older Edition
  • Edition number: 1
  • Pages: 304
  • Product dimensions: 8.26 (w) x 10.82 (h) x 0.62 (d)

Read an Excerpt

For many years, I wished for a book that could be used by students to learn about documentation, while at the same time be used by clinicians to improve the quality of documentation in the field. Eventually, I realized that I could, and should, write that book. As a college professor, I spend a great deal of time reading written work produced by occupational therapy students. As a peer reviewer, I read client charts that insurance companies are unsure about; the charts that are so poorly written that the insurers cannot decide whether the services are medically necessary and appropriate.

For these reasons, I decided to begin the long and challenging task of writing this book. It has taken over three years from the time I started talking about writing it to the actual printing of the book. Federal rules and professional standards changed while I was writing this book, forcing me to revise and add topics as the book evolved.

During the process of writing this book, I learned even more about writing. I learned that I write better in the morning than in the afternoon. I learned that I have difficulty knowing when to use the word "that" (refers to a specific object) as opposed to the word "which" (not specific to an object). I learned the difference between "assure" (to convince or to promise) and "ensure" (to make certain). I learned about comma and semicolon placement in sentences. Just because I pause when I speak the sentence out loud does not mean that rules of proper punctuation call for a comma. I learned the difference between a hyphen, an em dash, and an en dash. Finally, I learned to say "finally," instead of "lastly."

My hope for this book is that it gets used;that it is not simply put up on a shelf. I want it to be written in, to have pages flagged, and to have the spine well broken from repeated use. Normally, I would be appalled at the vision of food-stained, rumpled pages in a textbook. But I think this book is different. If it retains its original pristine condition, then it hasn't served its reader well.

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Table of Contents

SECTION I: USE OF LANGUAGE 1

Chapter 1 Introduction

Chapter 2 Professional Communication

Chapter 3 Buzzwords, Jargon, and Abbreviations

Chapter 4 The Occupational Therapy Practice Framework and Other Documents

Chapter 5 Impact of Models and Frames of Reference

Chapter 6 Document with CARE: General Tips for Good Documentation

SECTION II: ETHICAL AND LEGAL CONSIDERATIONS

Chapter 7 Introduction

Chapter 8 Confidentiality and Records Retention

Chapter 9 Fraud

Chapter 10 Plagiarism

SECTION III: CLINICAL DOCUMENTATION

Chapter 11 Introduction

Chapter 12 Electronic Health Records

Chapter 13 Client Identification: Referral and Screening

Chapter 14 Evaluation Reports

Chapter 15 Goal Writing

Chapter 16 Intervention Plans

Chapter 17 SOAP and Other Methods of Documenting Ongoing Intervention

Chapter 18 Discontinuation Summaries

SECTION IV: SCHOOL SYSTEM DOCUMENTATION

Chapter 19 Introduction

Chapter 20 Notice and Consent Forms

Chapter 21 Individualized Family Service Plans

Chapter 22 Individualized Education Program

SECTION V: ADMINISTRATIVE DOCUMENTATION

Chapter 23 Introduction

Chapter 24 Incident Reports

Chapter 25 Appeal Letters

Chapter 26 Meeting Minutes

Chapter 27 Grant Writing

Chapter 28 Policies and Procedures

Chapter 29 Job Descriptions

Index

Online Appendices:

Appendix A Grammar and Spelling Review

Appendix B Excerpts from Medicare Standards

Appendix C Model Forms: IEP, Prior Written Notice, and Excerpts from Procedural Safeguards

Appendix D Reproducible Sample Forms

Appendix E Summary of the Occupational Therapy Practice

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