Documenting Occupational Therapy Practice

Name: Documenting Occupational Therapy Practice
Price: 7.86 USD
Availability: InStock
ISBN: 9780130452146

ISBN-10: 0130452149

ISBN-13: 9780130452146

Edition: 2005

Authors: Karen M. Sames

List price: $42.00

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Written for introductory courses in occupational therapy and administrative documentation, this text takes a global look at documentation in occupational therapy, examining both the technical aspect of all forms of documentation and the ethical, legal and language issues related to documentation.

Book details

List price: $42.00
Copyright year: 2005
Publisher: Prentice Hall PTR
Publication date: 2/27/2004
Binding: Paperback
Pages: 304
Size: 8.25" wide x 10.75" long x 0.50" tall
Weight: 1.386
Language: English



Preface


Acknowledgments


Introduction



Use of Language



Buzzwords, Jargon, and Abbreviations


Introduction


Buzzwords


Jargon


Abbreviations


Summary


References



The Occupational Therapy Practice Framework and Other Documents


Introduction


International Classification of Functioning, Disability, and Health


Uniform Terminology


Occupational Therapy Practice Framework


Specific Occupational Therapy Terms


Summary


References



Impact of Models and Frames of Reference


Introduction


Descriptions of Models and Frames of Reference


How Models and Frames of Reference Are Reflected in Documentation


Summary


References



Document with CARE: General Tips for Good Documentation


Introduction


Clarity


Accuracy


Relevance


Exceptions


Summary


References



Ethical and Legal Considerations



Confidentiality and Records Retention


Introduction


Confidentiality


Ethical Responsibility


State Laws


Health Insurance Portability and Accountability Act


Family Education Rights and Privacy Act of 1974 and the Individuals with Disabilities Education Act, 1997 Revision


Records Retention


Summary


References



Fraud


Introduction


Medicare Fraud


Other Forms of Fraud


Summary


References



Plagiarism


Introduction


American Psychological Association Standards


Types of Plagiarism


Preventing Plagiarism


Summary


References



Clinical Documentation



Client Identification (Referral and Screening)


Introduction


Referrals


Role Delineation of Referrals


Orders


Screenings


Role Delineation for Screenings


Contact Note


Summary


References



Evaluation Reports


Introduction


Core Concepts of Evaluations


Components of an Evaluation Report


Role Delineation in the Occupational Therapy Evaluation Process


Writing the Report


Re-evaluation


Summary


References



Goal Writing


Introduction


Role Delineation in Goal Writing


Goal Directions


Goal Specifics


Formats for Goal Writing


Summary


References



Intervention Plans


Introduction


Role Delineation in Intervention Planning


Concepts for Intervention Planning


Parts of an Intervention Plan


Summarizing Progress


Documenting Intervention Strategies


Sample Intervention Plans


Revising Intervention Plans


Summary


References



SOAP and Other Methods of Documenting Ongoing Intervention


Introduction


Role Delineation for Progress Reporting


SOAP Notes


DAP Notes


Narrative Notes


Progress Flow Sheets


Attendance Logs


Photographic and Video Documentation


Summary


References



Discontinuation Summaries


Introduction


Role Delineation in Discontinuation


Components of a Discontinuation Summary


SOAP Format


Summary


References



School System Documentation



Notice and Consent Forms


Introduction


Service Coordination


Types of Notice and Consent Forms


Summary


References



Individualized Family Service Plans


Introduction


IFSP Requirements


Evaluation


Present Levels of Development


Family Information, Resources, and Concerns


Outcomes


Major Outcomes


Environmental Statement


Starting Date and Duration of Services


Service Coordinator


Transition to Preschool Services


Other Documentation


Summary


References



Individualized Education Program


Introduction


Evaluation Process


Present Level of Educational Performance


Goal Writing


Special Education and Related Services


Participation with Non-Disabled Children


Participation in State and District-Wide Tests


Dates and Places


Transition


Measuring Progress


Summary


References



Administrative Documentation



Incident Reports


Introduction


Legal Considerations


Recording Information on an Incident Report Form and Client Record


Summary


References



Appeal Letters


Introduction


Appeals Letters as Opportunities to Educate


Writing an Appeal Letter


Medicare Appeals


Appeals to Private Insurers (including HMOs)


Summary


References



Meeting Minutes


Introduction


Overview of Meeting Minutes


Commonalities


Taking Minutes


Formats


Summary


References



Grant Writing


Introduction


What Grants Are


Where to Find Grant Opportunities


General Grant-Writing Tips


Writing a Grant to Fund a New Program


Writing Other Types of Grants


Summary


References



Policies and Procedures


Introduction


Policies


Procedures


Writing Policies and Procedures


Summary


References



Answers to Selected Exercises



Grammar and Spelling Review



AOTA Standards of Practice



AOTA Guidelines to Occupational Therapy Documentation



AOTA Code of Ethics



Medicare Standards



Reproducible Sample Forms



Summary of the Occupational Therapy Practice Framework


Index