Documenting Occupational Therapy Practice

Documenting Occupational Therapy Practice

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For introductory courses in occupational therapy and administrative documentation. Taking a global look at documentation in occupational therapy, this text examines both the technical, "how-to" aspect of all forms of clinical, school-based, and administrative documentation, and the ethical, legal, and language issues related to documentation. Soap notes as well as other forms of documentation are discussed more

Product details

  • Paperback | 304 pages
  • 209.8 x 274.83 x 16mm | 684.92g
  • Pearson Education (US)
  • Prentice Hall
  • Upper Saddle River, United States
  • English
  • 0130452149
  • 9780130452146
  • 1,442,417

Table of contents

INTRODUCTION. Who, What, Where, When, Why of Documentation. SECTION 1. USE OF LANGUAGE. 1. Buzzwords, Jargon, and Abbreviations. 2. The Occupational Therapy Practice Framework and Other Documents. 3. Impact of Models and Frames of Reference. 4. Document with C.A.R.E. (general tips for good documentation). SECTION 2. ETHICAL AND LEGAL CONSIDERATIONS. 5. Confidentiality and Records Retention. 6. Fraud. 7. Plagiarism. SECTION 3. DOCUMENTATION OF THE OT PROCESS (CLINICAL SETTINGS). 8. Client Identification (referral, screening). 9. Evaluation Reports. 10. Goal Writing. 11. Intervention Plans. 12. SOAP and Other Methods of Documenting Ongoing Intervention. 13. Discontinuation Plans. SECTION 4. DOCUMENTATION OF THE OT PROCESS (EDUCATIONAL SETTINGS). 14. Notice and Consent Forms. 15. Individual Family Service Plan (IFSP). 16. Individual Education Program (IEP). SECTION 5. ADMINISTRATIVE DOCUMENTATION. 17. Incident Reports. 18. Appeal Letters. 19. Meeting Minutes. 20. Grant Writing. 21. Policies and Procedures. Appendix A: Answers to Selected Exercises. Appendix B: Grammar and Spelling Review. Appendix C: AOTA Standards of Practice. Appendix D: AOTA Guidelines to Occupational Therapy. Appendix E: AOTA Code of Ethics. Appendix F: AOTA Standards of Practice. Appendix G: Medicare Standards. Appendix H: Reproducible Sample more

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17 ratings
3.94 out of 5 stars
5 29% (5)
4 41% (7)
3 24% (4)
2 6% (1)
1 0% (0)
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