| Document Type
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BL
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| Record Number
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623176
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| Doc. No
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dltt
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| Main Entry
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Sames, Karen M.
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| Title & Author
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Documenting occupational therapy practice /\ Karen M. Sames
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| Edition Statement
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Third edition
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| Page. NO
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xx, 290 pages :: illustrations ;; 28 cm
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| ISBN
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9780133110494
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: 0133110494
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| Bibliographies/Indexes
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Includes bibliographical references and index
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| Contents
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SECT. 1. USE OF LANGUAGE. Overview of the use of language in documentation -- Professional communication -- Buzzwords, jargon, and abbreviations -- The occupational therapy practice framework and important other important documents -- Impact of models and frames of reference -- Document with CARE: general tips for good documentation -- SECT. 2. ETHICAL AND LEGAL CONSIDERATIONS. Overview of ethical and legal considerations -- Confidentiality and records retention -- Fraud and abuse -- Plagiarism -- SECT 3. CLINICAL DOCUMENTATION. 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 -- SECT. 4. SCHOOL SYSTEM DOCUMENTATION. Overview of school system documentation -- Procedural safeguards: notice and consent forms -- Individualized family service plans -- Individualized education program -- SECT. 5. ADMINISTRATIVE DOCUMENTATION. Overview of administration documentation -- Incident reports -- Appeal letters -- Meeting minutes -- Grant writing -- Policies and procedures -- Job descriptions
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| Subject
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Occupational therapy-- Practice
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| Subject
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Medical records
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| Subject
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Medical protocols
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| Subject
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Occupational Therapy-- organization administration
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| Subject
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Medical Records-- standards
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| LC Classification
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RM735.4.S264 2015
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RM735.4.S264 2015
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| NLM classification
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WB 555
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2014 K-272
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