Documenting Occupational Therapy Practice, 3rd edition

Published by Pearson (August 6, 2014) © 2015

  • Karen M. Sames
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This product is expected to ship within 5-7 business days for Australian customers.

For courses in Foundations of Occupational Therapy, Intro to Occupational Therapy Practice, Occupational Therapy Practice Skills, and Occupational Therapy Management.

Documenting Occupational Therapy Practice, 3rd Edition 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 3rd Edition has been fully updated to reflect current AOTA official documents and new electronic documentation tools, and has been reorganised to improve readability. Effective review tools help readers truly master documentation techniques and strategies.

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 familiarise students with current documentation technologies.
  • Effective learning tools: Review exercises and numerous reference tools help students truly master text material.
  • 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

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