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Documenting Occupational Therapy Practice 3rd Edition by Karen Sames, ISBN-13: 978-0133110494

Documenting Occupational Therapy Practice 3rd Edition by Karen Sames, ISBN-13: 978-0133110494

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Documenting Occupational Therapy Practice 3rd Edition by Karen Sames, ISBN-13: 978-0133110494

[PDF eBook eTextbook]

  • Publisher: ‎ Pearson; 3rd edition (August 6, 2014)
  • Language: ‎ English
  • 320 pages
  • ISBN-10: ‎ 9780133110494
  • ISBN-13: ‎ 978-0133110494

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.

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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