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
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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