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Documenting Occupational Therapy Practice

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ISBN-10: 0130452149

ISBN-13: 9780130452146

Edition: 2005

Authors: Karen M. Sames

List price: $42.00
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Description:

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.
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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