Documenting Occupational Therapy Practice

by Sames, Karen M., MBA, OTR/L

• ISBN13: 9780131999480
• ISBN10: 0131999486
• Edition: 2nd
• Format: Paperback
• Copyright: 2009-07-29
• Publisher: Pearson

Summary

Taking a global look at documentation in occupational therapy, this book examines both the technical, “how-to” aspect of all forms of clinical, school-based, and administrative documentation, and the ethical, legal, and language issues related to documentation. Soap notes as well as other forms of documentation are discussed throughout.

Sections in this book include: Use of Language, Ethical and Legal Considerations ,Clinical Documentation, School System Documentation, and Administrative

Documentation.

There are also extensive appendices on AOTA Standards of Practice, AOTA Guidelines to Occupational Therapy Documentation, and AOTA Code of Ethics. This book can be used by students to learn about documentation and by clinicians to improve the quality of documentation in the field.

“The depth and breadth…clearly outshines any other work on the subject I have seen.” - William R. Croninger, MA, OTR/L University of New England

“The author has a style that is entertaining, yet factual. She manages to make a potentially deadly topic interesting, funny and informative.” - Cathy Nielson, MPH, OTR/L, The University of North Carolina at Chapel Hill

“This text provides a complete knowledge base of information related to documentation that will serve readers well throughout their professional careers.” - Kathy Clark Tuminski, MA, OTR/L University of Kentucky

Table of Contents

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