Documenting occupational therapy practice /
Karen M. Sames
- 3rd ed.
- Upper Saddle River, NJ : Pearson, 2015.
- xx, 290 p. : ill.; diagrs.
Includes bibliographical references.
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.
9780133110494 (pbk.)
Occupational therapy--Organization & administration. Medical records.--standards.