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

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.

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.