Documenting Occupational Therapy Practice, 3rd edition

Published by Pearson (March 9, 2015) © 2015

  • Karen M. Sames
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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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