9780130452146

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.

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

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

What is included with this book?

The New copy of this book will include any supplemental materials advertised. Please check the title of the book to determine if it should include any access cards, study guides, lab manuals, CDs, etc.

The Used, Rental and eBook copies of this book are not guaranteed to include any supplemental materials. Typically, only the book itself is included. This is true even if the title states it includes any access cards, study guides, lab manuals, CDs, etc.

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.

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Documenting Occupational Therapy Practice

Documenting Occupational Therapy Practice

0130452149

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