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.

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