Documenting Occupational Therapy Practice Book

Introduction

¼ Section I ¼

Use of Language 1

Introduction

Professional Documentation

Professional Communication

Memos

Letters

E-mail

Structure of This Section of the Book

References

Chapter 1 Buzzwords, Jargon, and Abbreviations

Introduction

Buzzwords

Jargon

Abbreviations

Summary

References

Chapter 2 The Occupational Therapy Practice Framework and Other Documents

Introduction

International Classification of Functioning, Disability, and Health

Uniform Terminology

Occupational Therapy Practice Framework

Specific Occupational Therapy Terms

Summary

References

Chapter 3 Impact of Models and Frames of Reference

Introduction

Descriptions of Models and Frames of Reference

How Models and Frames of Reference Are Reflected in Documentation

Summary

References

Chapter 4 Document with CARE: General Tips for Good Documentation

Introduction

Clarity

Accuracy

Relevance

Exceptions

Summary

References

¼ Section II ¼

Ethical and Legal Considerations 37

Introduction

Avoiding Legal Action Through Documentation

Structure of This Section of the Book

References

Chapter 5 Confidentiality and Records Retention

Introduction

Confidentiality

Ethical Responsibility

State Laws

Health Insurance Portability and Accountability Act

Family Education Rights and Privacy Act of 1974 and the Individuals with Disabilities Education Act, 2004 Revision

Records Retention

Summary

References

Chapter 6 Fraud

Introduction

Medicare Fraud

Other Forms of Fraud

Ethical Standards

Summary

References

Chapter 7 Plagiarism

Introduction

American Psychological Association Standards

Types of Plagiarism

Preventing Plagiarism

Summary

References

¼ Section III ¼

Clinical Documentation 57

Introduction

Clinical Documentation

Role Delineation for Documentation

AOTA Standards for Documentation

Electronic Medical Record

Structure of This Section of the Book

References

Chapter 8 Client Identification (Referral and Screening)

Introduction

Referrals

Role Delineation of Referrals

Orders

Screenings

Role Delineation for Screenings

Contact Note

Medicare Compliance

Summary

References

Chapter 9 Evaluation Reports

Introduction

Role Delineation in the Occupational Therapy Evaluation Process

Core Concepts of Evaluations

The Evaluation Process

Components of an Evaluation Report

Writing the Report

Re-evaluation

Medicare Compliance

Summary

References

Chapter 10 Goal Writing

Introduction

Role Delineation in Goal Writing

Goal Directions

Goal Specifics

Formats for Goal Writing

Summary

References

Chapter 11 Intervention Plans

Introduction

Role Delineation in Intervention Planning

Medicare Compliance

Concepts for Intervention Planning

Parts of an Intervention Plan

Summarizing Progress

Documenting Intervention Strategies

Sample Intervention Plans

Revising Intervention Plans

Summary

References

Chapter 12 SOAP and Other Methods of Documenting Ongoing Intervention

Introduction

Role Delineation for Progress Reporting

SOAP Notes

DAP Notes

Narrative Notes

Progress Flow Sheets

Attendance Logs

Photographic and Video Documentation

Medicare Compliance

Summary

References

Chapter 13 Discontinuation Summaries

Introduction

Role Delineation in Discontinuation

Medicare Compliance

Components of a Discontinuation Summary

SOAP Format

Summary

References

¼ Section IV ¼

School System Documentation

Introduction

Overview of School System Documentation

Role Delineation in School System Documentation

Structure of This Section of the Book

References

Chapter 14 Notice and Consent Forms

Introduction

Service Coordination

Types of Notice and Consent Forms

Summary

References

Chapter 15 Individualized Family Service Plans

Introduction

IFSP Requirements

Evaluation

Present Levels of Development

Family Information, Resources, and Concerns

Outcomes

Services Provided

Environmental Statement

Transition to Preschool Services

Other Documentation

Summary

References

Chapter 16 Individualized Education Program

Introduction

Evaluation Process

Present Level of Educational Performance

Goal Writing

Special Education and Related Services

Participation with Non-Disabled Children

Participation in State and District-Wide Tests

Dates and Places

Transition

Measuring Progress

Summary

References

¼ Section V ¼

Administrative Documentation

Introduction

Structure of This Section of the Book

Chapter 17 Incident Reports

Introduction

Legal Considerations

Recording Information on an Incident Report Form and Client Record

Summary

References

Chapter 18 Appeal Letters

Introduction

Appeals Letters as Opportunities to Educate

Writing an Appeal Letter

Medicare Appeals

Appeals to Private Insurers (including HMOs)

Summary

References

Chapter 19 Meeting Minutes

Introduction

Overview of Meeting Minutes

Commonalities

Taking Minutes

Formats

Summary

References

Chapter 20 Grant Writing

Introduction

What Grants Are

Where to Find Grant Opportunities

General Grant-Writing Tips

Writing a Grant to Fund a New Program

Writing Other Types of Grants

Summary

References

Chapter 21 Policies and Procedures

Introduction

Policies

Procedures

Writing Policies and Procedures

Summary

References

Chapter 22 Job Descriptions

Introduction

Legal and Regulatory Requirements

Gathering Information for Job Descriptions

Parts of Job Descriptions

Summary

References

Appendix A: Answers to Selected Exercises

Appendix B: Grammar and Spelling Review

Appendix C: AOTA Standards of Practice

Appendix D: AOTA Guidelines to Occupational Therapy Documentation

Appendix E: AOTA Code of Ethics

Appendix F: Excerpts from Medicare Standards

Appendix G: excerpts from Model forms for part b of idea 2004

Appendix H: Reproducible Sample Forms

Appendix I: Summary of the Occupational Therapy practice Framework

Index