Documenting occupational therapy practice / Karen M. Sames, OTD, MBA, OTR/L, FAOTA, Associate Professor of Occupational Science and Occupational Theraphy, St. Catherine University, St. Paul, Minnesota.
By: Sames, Karen M [author.].
Boston : Pearson, 2015Edition: Third edition.Description: xx, 290 pages : illustrations ; 28 cm.ISBN: 9780133110494.Subject(s): Occupational Therapy -- organization & administration | Medical Records -- standardsGenre/Form: Print books.| Current location | Call number | Status | Date due | Barcode | Item holds |
|---|---|---|---|---|---|
| On Shelf | RM735.4 .S264 2015 (Browse shelf) | Available | AU0000000003237 |
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| RM735 .O2 M38 2015 Theoretical basis of occupational therapy / | RM735 .S27 2014 Occupational therapy in community-based practice settings / | RM735.4 .S23 2018 Introduction to occupational therapy / | RM735.4 .S264 2015 Documenting occupational therapy practice / | RM930 .O934 2019 Oxford handbook of rehabilitation medicine / | RS55.2 .E23 2018 Bottle of lies : the inside story of the generic drug boom / | RS56 .B474 2009 Communication skills for pharmacists : building relationships, improving patient care / |
Includes bibliographical references and index.
Buzzwords, jargon, and abbreviations -- 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 -- Ethical and legal considerations -- Confidentiality and records retention -- Fraud and abuse -- Plagiarism -- 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 -- School system documentation -- Procedural safeguards: notice and consent forms -- Individualized family service plans -- Individualized education program -- Administrative documentation -- Incident reports -- Appeal letters -- Meeting minutes -- Grant writing -- Policies and procedures -- Job descriptions.