Documenting occupational therapy practice

Documenting Occupational Therapy Practice, Third 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 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<U+2019>s accompanying website provides additional learning resources that can be accessed on the go.

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. (Publisher).

Overview of the use of language in documentation -- Professional communication -- Buzzwords, jargon, and abbreviations -- The occupational therapy practice framework and important other documents -- Impact of models and frames of reference -- Document with CARE: general tips for good documentation -- Overview of ethical and legal considerations -- Confidentiality and records retention -- Fraud and abuse -- Plagiarism -- Overview of clinical documentation -- Electronic health record -- Client identification: referral and screening -- Evaluation reports -- Goal writing -- Intervention plans -- SOAP and other methods of documenting ongoing intervention -- Discharge summaries -- Overview of school system documentation -- Procedural safeguards: notice and consent forms -- Individualized family service plans -- Individualized education program -- Overview of administrative documentation -- Incident reports -- Appeal letters -- Meeting minutes -- Grant writing -- Policies and procedures -- Job descriptions.