Documenting Occupational Therapy Practice
Pearson (Verlag)
978-0-13-199948-0 (ISBN)
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Documentation. There are also extensive appendices on AOTA Standards of Practice, AOTA Guidelines to Occupational Therapy Documentation, and AOTA Code of Ethics. This book can be used by students to learn about documentation and by clinicians to improve the quality of documentation in the field.
Introduction
¼ Section I ¼
Use of Language 1
Introduction
Professional Documentation
Professional Communication
Memos
Letters
E-mail
Structure of This Section of the Book
References
Chapter 1 Buzzwords, Jargon, and Abbreviations
Introduction
Buzzwords
Jargon
Abbreviations
Summary
References
Chapter 2 The Occupational Therapy Practice Framework and Other Documents
Introduction
International Classification of Functioning, Disability, and Health
Uniform Terminology
Occupational Therapy Practice Framework
Specific Occupational Therapy Terms
Summary
References
Chapter 3 Impact of Models and Frames of Reference
Introduction
Descriptions of Models and Frames of Reference
How Models and Frames of Reference Are Reflected in Documentation
Summary
References
Chapter 4 Document with CARE: General Tips for Good Documentation
Introduction
Clarity
Accuracy
Relevance
Exceptions
Summary
References
¼ Section II ¼
Ethical and Legal Considerations 37
Introduction
Avoiding Legal Action Through Documentation
Structure of This Section of the Book
References
Chapter 5 Confidentiality and Records Retention
Introduction
Confidentiality
Ethical Responsibility
State Laws
Health Insurance Portability and Accountability Act
Family Education Rights and Privacy Act of 1974 and the Individuals with Disabilities Education Act, 2004 Revision
Records Retention
Summary
References
Chapter 6 Fraud
Introduction
Medicare Fraud
Other Forms of Fraud
Ethical Standards
Summary
References
Chapter 7 Plagiarism
Introduction
American Psychological Association Standards
Types of Plagiarism
Preventing Plagiarism
Summary
References
¼ Section III ¼
Clinical Documentation 57
Introduction
Clinical Documentation
Role Delineation for Documentation
AOTA Standards for Documentation
Electronic Medical Record
Structure of This Section of the Book
References
Chapter 8 Client Identification (Referral and Screening)
Introduction
Referrals
Role Delineation of Referrals
Orders
Screenings
Role Delineation for Screenings
Contact Note
Medicare Compliance
Summary
References
Chapter 9 Evaluation Reports
Introduction
Role Delineation in the Occupational Therapy Evaluation Process
Core Concepts of Evaluations
The Evaluation Process
Components of an Evaluation Report
Writing the Report
Re-evaluation
Medicare Compliance
Summary
References
Chapter 10 Goal Writing
Introduction
Role Delineation in Goal Writing
Goal Directions
Goal Specifics
Formats for Goal Writing
Summary
References
Chapter 11 Intervention Plans
Introduction
Role Delineation in Intervention Planning
Medicare Compliance
Concepts for Intervention Planning
Parts of an Intervention Plan
Summarizing Progress
Documenting Intervention Strategies
Sample Intervention Plans
Revising Intervention Plans
Summary
References
Chapter 12 SOAP and Other Methods of Documenting Ongoing Intervention
Introduction
Role Delineation for Progress Reporting
SOAP Notes
DAP Notes
Narrative Notes
Progress Flow Sheets
Attendance Logs
Photographic and Video Documentation
Medicare Compliance
Summary
References
Chapter 13 Discontinuation Summaries
Introduction
Role Delineation in Discontinuation
Medicare Compliance
Components of a Discontinuation Summary
SOAP Format
Summary
References
¼ Section IV ¼
School System Documentation
Introduction
Overview of School System Documentation
Role Delineation in School System Documentation
Structure of This Section of the Book
References
Chapter 14 Notice and Consent Forms
Introduction
Service Coordination
Types of Notice and Consent Forms
Summary
References
Chapter 15 Individualized Family Service Plans
Introduction
IFSP Requirements
Evaluation
Present Levels of Development
Family Information, Resources, and Concerns
Outcomes
Services Provided
Environmental Statement
Transition to Preschool Services
Other Documentation
Summary
References
Chapter 16 Individualized Education Program
Introduction
Evaluation Process
Present Level of Educational Performance
Goal Writing
Special Education and Related Services
Participation with Non-Disabled Children
Participation in State and District-Wide Tests
Dates and Places
Transition
Measuring Progress
Summary
References
¼ Section V ¼
Administrative Documentation
Introduction
Structure of This Section of the Book
Chapter 17 Incident Reports
Introduction
Legal Considerations
Recording Information on an Incident Report Form and Client Record
Summary
References
Chapter 18 Appeal Letters
Introduction
Appeals Letters as Opportunities to Educate
Writing an Appeal Letter
Medicare Appeals
Appeals to Private Insurers (including HMOs)
Summary
References
Chapter 19 Meeting Minutes
Introduction
Overview of Meeting Minutes
Commonalities
Taking Minutes
Formats
Summary
References
Chapter 20 Grant Writing
Introduction
What Grants Are
Where to Find Grant Opportunities
General Grant-Writing Tips
Writing a Grant to Fund a New Program
Writing Other Types of Grants
Summary
References
Chapter 21 Policies and Procedures
Introduction
Policies
Procedures
Writing Policies and Procedures
Summary
References
Chapter 22 Job Descriptions
Introduction
Legal and Regulatory Requirements
Gathering Information for Job Descriptions
Parts of Job Descriptions
Summary
References
Appendix A: Answers to Selected Exercises
Appendix B: Grammar and Spelling Review
Appendix C: AOTA Standards of Practice
Appendix D: AOTA Guidelines to Occupational Therapy Documentation
Appendix E: AOTA Code of Ethics
Appendix F: Excerpts from Medicare Standards
Appendix G: excerpts from Model forms for part b of idea 2004
Appendix H: Reproducible Sample Forms
Appendix I: Summary of the Occupational Therapy practice Framework
Index
| Erscheint lt. Verlag | 21.1.2010 |
|---|---|
| Sprache | englisch |
| Maße | 216 x 276 mm |
| Gewicht | 646 g |
| Themenwelt | Medizin / Pharmazie ► Physiotherapie / Ergotherapie ► Ergotherapie |
| ISBN-10 | 0-13-199948-6 / 0131999486 |
| ISBN-13 | 978-0-13-199948-0 / 9780131999480 |
| Zustand | Neuware |
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