Documenting Occupational Therapy Practice

Series
Prentice Hall
Author
Karen M. Sames  
Publisher
Pearson
Cover
Softcover
Edition
3
Language
English
Total pages
312
Pub.-date
August 2014
ISBN13
9780133110494
ISBN
0133110494
Related Titles



Description

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

 

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.

Features

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

 

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.

Hallmark Features

 

Comprehensive coverage of all areas of practice:

  • Sames offers unmatched breadth of coverage for occupational therapy documentation, covering general documentation principles, clinical documentation, electronic documentation, school system documentation, and documentation of administrative tasks.
  • Students of occupational therapy and professionals looking to brush up on their documentation skills will find the text an indispensable reference they will turn to again and again.
  • NEW! Chapters have been reorganized to improve consistency across chapters. For example, the sequence of chapter topics has been standardized to help readers locate information quickly.
  • NEW! New chapters have been added to introduce each section of the book. These chapters help prepare readers for the topics to come and facilitate learning by providing context for the content in each section.
  • NEW! Creating intervention plans is now explored in a dedicated chapter.
  • NEW! Updates have been made throughout the text to reflect changes to Medicare. Appendix B also outlines several of the new Medicare standards.

Practical techniques and strategies that prepare students for the workplace:

  • Chapters provide step-by-step strategies for drafting effective documentation and communications. Readers come away with techniques they can directly apply in the workplace.
  • Sample forms are provided in Appendix E to familiarize students with common forms and enable them to practice techniques presented in the text.
  • NEW! Discussion of the SBAR technique for organizing one’s thoughts for verbal and written communication with physicians has been added.
  • NEW! Forms in Appendix E have been updated to reflect current practices.
  • UPDATED! Chapters have been updated to reflect recent revisions to core AOTA official documents. 

Exploration of ethical and legal issues:

  • Chapters go beyond simple how-to instructions to explore the ethical and legal issues related to documenting occupational therapy. Discussions help students identify and resolve or avoid ethical and legal conflicts in the workplace.
  • NEW! Guidelines for correcting errors in documentation have been added to Section 3.  

Coverage of electronic documentation:

  • NEW! Reflecting the shift towards electronic documentation, a new chapter focusing on electronic health records (EHR) has been added to prepare students for facilities that utilize digital documentation.
  • NEW! Screenshots of computerized documentation have been added to familiarize students with popular documentation software.
  • NEW! Chapter 2 has a new section on texting as a form of professional communication. 

Effective learning tools:

  • Exercises in every chapter challenge readers to apply their knowledge to real-life situations.
  • An appendix on grammar and spelling points out common mistakes—an excellent resource for creating clear and accurate documentation.
  • The text’s accompanying website provides additional references and learning resources.
  • UPDATED! Exercises have been updated and new exercises have been added throughout the text.
  • NEW! A new test bank is available to assess the new information in the Third Edition.

New to this Edition

The Third Edition has been extensively updated to incorporate new forms and best practices and recent trends in the occupational therapy field.

 

Overview

 

Comprehensive coverage of all areas of practice:

  • NEW! Chapters have been reorganized to improve consistency across chapters. For example, the sequence of chapter topics has been standardized to help readers locate information quickly.
  • NEW! New chapters have been added to introduce each section of the book. These chapters help prepare readers for the topics to come and facilitate learning by providing context for the content in each section.
  • NEW! Creating intervention plans is now explored in a dedicated chapter.
  • NEW! Updates have been made throughout the text to reflect changes to Medicare. Appendix B also outlines several of the new Medicare standards.

Practical techniques and strategies that prepare students for the workplace:

  • NEW! Discussion of the SBAR technique for organizing one’s thoughts for verbal and written communication with physicians has been added.
  • NEW! Forms in Appendix E have been updated to reflect current practices.
  • UPDATED! Chapters have been updated to reflect recent revisions to core AOTA official documents. 

Exploration of ethical and legal issues:

  • NEW! Guidelines for correcting errors in documentation have been added to Section 3. 

Coverage of electronic documentation:

  • NEW! Reflecting the shift towards electronic documentation, a new chapter focusing on electronic health records (EHR) has been added to prepare students for facilities that utilize digital documentation.
  • NEW! Screenshots of computerized documentation have been added to familiarize students with popular documentation software.
  • NEW! Chapter 2 has a new section on texting as a form of professional communication. 

Effective learning tools:

  • UPDATED! Exercises have been updated and new exercises have been added throughout the text.
  • NEW! A new test bank is available to assess the new information in the Third Edition.

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