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
