Documenting Occupational Therapy Practice

by Sames, Karen M.

• ISBN13: 9780130452146
• ISBN10: 0130452149
• Format: Paperback
• Copyright: 2005-01-01
• Publisher: Prentice Hall

Summary

For introductory courses in occupational therapy and administrative documentation. Taking a global look at documentation in occupational therapy, this text 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.

Author Biography

Karen M. Sames, MBA, OTR/L: Associate Professor of Occupational Science and Occupational Therapy, The College of St. Catherine, St. Paul, Minnesota

Table of Contents

PREFACE	ix
ACKNOWLEDGMENTS	x
INTRODUCTION	xiii
SECTION I USE OF LANGUAGE	1	(36)
Chapter 1 Buzzwords, Jargon, and Abbreviations	3	(10)
Introduction	3	(1)
Buzzwords	3	(1)
Jargon	4	(1)
Abbreviations	5	(6)
Summary	11	(1)
References	12	(1)
Chapter 2 The Occupational Therapy Practice Framework and Other Documents	13	(8)
Introduction	13	(1)
International Classification of Functioning, Disability, and Health	13	(1)
Uniform Terminology	13	(1)
Occupational Therapy Practice Framework	14	(4)
Specific Occupational Therapy Terms	18	(1)
Summary	19	(1)
References	20	(1)
Chapter 3 Impact of Models and Frames of Reference	21	(10)
Introduction	21	(1)
Descriptions of Models and Frames of Reference	21	(1)
How Models and Frames of Reference Are Reflected in Documentation	22	(7)
Summary	29	(1)
References	30	(1)
Chapter 4 Document with CARE: General Tips for Good Documentation	31	(6)
Introduction	31	(1)
Clarity	31	(1)
Accuracy	31	(1)
Relevance	32	(1)
Exceptions	33	(2)
Summary	35	(1)
References	35	(2)
SECTION II ETHICAL AND LEGAL CONSIDERATIONS	37	(20)
Chapter 5 Confidentiality and Records Retention	41	(6)
Introduction	41	(1)
Confidentiality,	41	(1)
Ethical Responsibility	41	(1)
State Laws	42	(1)
Health Insurance Portability and Accountability Act	42	(2)
Family Education Rights and Privacy Act of 1974 and the Individuals with Disabilities Education Act, 1997 Revision	44	(1)
Records Retention	45	(1)
Summary	46	(1)
References	46	(1)
Chapter 6 Fraud	47	(4)
Introduction	47	(1)
Medicare Fraud	47	(1)
Other Forms of Fraud	48	(1)
Summary	49	(1)
References	49	(2)
Chapter 7 Plagiarism	51	(6)
Introduction	51	(1)
American Psychological Association Standards	51	(1)
Types of Plagiarism	51	(2)
Preventing Plagiarism	53	(1)
Summary	54	(1)
References	55	(2)
SECTION III CLINICAL DOCUMENTATION	57	(86)
Chapter 8 Client Identification (Referral and Screening)	61	(6)
Introduction	61	(1)
Referrals	61	(1)
Role Delineation of Referrals 61 Orders	62	(2)
Screenings	64	(1)
Role Delineation for Screenings	65	(1)
Contact Note	65	(1)
Summary	66	(1)
References	66	(1)
Chapter 9 Evaluation Reports	67	(12)
Introduction	67	(1)
Core Concepts of Evaluations	67	(1)
Components of an Evaluation Report	68	(1)
Role Delineation in the Occupational Therapy Evaluation Process	69	(2)
Writing the Report	71	(5)
Re-evaluation	76	(1)
Summary	76	(1)
References	77	(2)
Chapter 10 Goal Writing	79	(16)
Introduction	79	(1)
Role Delineation in Goal Writing	79	(1)
Goal Directions	79	(2)
Goal Specifics	81	(4)
Formats for Goal Writing	85	(7)
Summary	92	(1)
References	93	(2)
Chapter 11 Intervention Plans	95	(16)
Introduction	95	(1)
Role Delineation in Intervention Planning	96	(1)
Concepts for Intervention Planning	96	(1)
Parts of an Intervention Plan	97	(1)
Summarizing Progress	98	(3)
Documenting Intervention Strategies	101	(2)
Sample Intervention Plans	103	(1)
Revising Intervention Plans	103	(6)
Summary	109	(1)
References	109	(2)
Chapter 12 SOAP and Other Methods of Documenting Ongoing Intervention	111	(24)
Introduction	111	(1)
Role Delineation for Progress Reporting	111	(1)
SOAP Notes	112	(11)
DAP Notes	123	(3)
Narrative Notes	126	(3)
Progress Flow Sheets	129	(1)
Attendance Logs	130	(1)
Photographic and Video Documentation	131	(1)
Summary	132	(1)
References	132	(3)
Chapter 13 Discontinuation Summaries	135	(8)
Introduction	135	(1)
Role Delineation in Discontinuation	135	(1)
Components of a Discontinuation Summary	135	(2)
SOAP Format	137	(4)
Summary	141	(1)
References	142	(1)
SECTION IV SCHOOL SYSTEM DOCUMENTATION	143	(28)
Chapter 14 Notice and Consent Forms	145	(6)
Introduction	145	(1)
Service Coordination	145	(2)
Types of Notice and Consent Forms	147	(2)
Summary	149	(1)
References	149	(2)
Chapter 15 Individualized Family Service Plans	151	(8)
Introduction	151	(1)
IFSP Requirements	151	(1)
Evaluation	151	(2)
Present Levels of Development	153	(1)
Family Information, Resources, and Concerns	154	(1)
Outcomes	154	(1)
Major Outcomes	155	(1)
Environmental Statement	155	(1)
Starting Date and Duration of Services	156	(1)
Service Coordinator	156	(1)
Transition to Preschool Services	156	(1)
Other Documentation	156	(1)
Summary	157	(1)
References	157	(2)
Chapter 16 Individualized Education Program	159	(12)
Introduction	159	(2)
Evaluation Process	161	(1)
Present Level of Educational Performance	162	(2)
Goal Writing	164	(2)
Special Education and Related Services	166	(1)
Participation with Non-Disabled Children	167	(1)
Participation in State and District-Wide Tests	167	(1)
Dates and Places	167	(1)
Transition	168	(1)
Measuring Progress	168	(1)
Summary	168	(1)
References	168	(3)
SECTION V ADMINISTRATIVE DOCUMENTATION	171	(34)
Chapter 17 Incident Reports	173	(6)
Introduction	173	(1)
Legal Considerations	173	(1)
Recording Information on an Incident Report Form and Client Record	174	(3)
Summary	177	(1)
References	177	(2)
Chapter 18 Appeal Letters	179	(6)
Introduction	179	(1)
Appeals Letters as Opportunities to Educate	179	(1)
Writing an Appeal Letter	180	(1)
Medicare Appeals	180	(1)
Appeals to Private Insurers (including HMOs)	181	(2)
Summary	183	(1)
References	183	(2)
Chapter 19 Meeting Minutes	185	(8)
Introduction	185	(1)
Overview of Meeting Minutes	185	(1)
Commonalities	185	(1)
Taking Minutes	186	(1)
Formats	186	(5)
Summary	191	(1)
References	192	(1)
Chapter 20 Grant Writing	193	(8)
Introduction	193	(1)
What Grants Are	193	(1)
Where to Find Grant Opportunities	193	(2)
General Grant-Writing Tips	195	(1)
Writing a Grant to Fund a New Program	196	(3)
Writing Other Types of Grants	199	(1)
Summary	200	(1)
References	200	(1)
Chapter 21 Policies and Procedures	201	(4)
Introduction 201 Policies	201	(1)
Procedures	202	(1)
Writing Policies and Procedures	202	(2)
Summary 204 References	204	(1)
APPENDIX A: ANSWERS TO SELECTED EXERCISES	205	(20)
APPENDIX B: GRAMMAR AND SPELLING REVIEW	225	(8)
APPENDIX C: AOTA STANDARDS OF PRACTICE	233	(6)
APPENDIX D: AOTA GUIDELINES TO OCCUPATIONAL THERAPY DOCUMENTATION	239	(6)
APPENDIX E: AOTA CODE OF ETHICS	245	(4)
APPENDIX F: MEDICARE STANDARDS	249	(14)
APPENDIX G: REPRODUCIBLE SAMPLE FORMS	263	(18)
APPENDIX H: SUMMARY OF THE OCCUPATIONAL THERAPY PRACTICE FRAMEWORK	281	(3)
INDEX	284

Excerpts

For many years, I wished for a book that could be used by students to learn about documentation, while at the same time be used by clinicians to improve the quality of documentation in the field. Eventually, I realized that I could, and should, write that book. As a college professor, I spend a great deal of time reading written work produced by occupational therapy students. As a peer reviewer, I read client charts that insurance companies are unsure about; the charts that are so poorly written that the insurers cannot decide whether the services are medically necessary and appropriate. For these reasons, I decided to begin the long and challenging task of writing this book. It has taken over three years from the time I started talking about writing it to the actual printing of the book. Federal rules and professional standards changed while I was writing this book, forcing me to revise and add topics as the book evolved. During the process of writing this book, I learned even more about writing. I learned that I write better in the morning than in the afternoon. I learned that I have difficulty knowing when to use the word "that" (refers to a specific object) as opposed to the word "which" (not specific to an object). I learned the difference between "assure" (to convince or to promise) and "ensure" (to make certain). I learned about comma and semicolon placement in sentences. Just because I pause when I speak the sentence out loud does not mean that rules of proper punctuation call for a comma. I learned the difference between a hyphen, an em dash, and an en dash. Finally, I learned to say "finally," instead of "lastly." My hope for this book is that it gets used; that it is not simply put up on a shelf. I want it to be written in, to have pages flagged, and to have the spine well broken from repeated use. Normally, I would be appalled at the vision of food-stained, rumpled pages in a textbook. But I think this book is different. If it retains its original pristine condition, then it hasn't served its reader well.