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Documenting Occupational Therapy Practice

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Table of Contents

Introduction 1/4 Section I 1/4 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 1/4 Section II 1/4 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 1/4 Section III 1/4 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 1/4 Section IV 1/4 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 1/4 Section V 1/4 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

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