Table of contents for Documenting occupational therapy practice / Karen M. Sames.

Bibliographic record and links to related information available from the Library of Congress catalog. Note: Contents data are machine generated based on pre-publication information provided by the publisher. Contents may have variations from the printed book or be incomplete or contain other coding.

Contents
Preface
Acknowledgments
Reviewers
Section I: Use Of Language
	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 C.A.R.E.: General Tips For Good Documentation
		Introduction
		Clarity
		Accuracy
		Relevance
		Exceptions
		Summary
		References
		
Section II: Ethical And Legal Considerations
	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, 1997 Revision
		Records Retention
		Summary
		References
	Chapter 6: Fraud
		Introduction
		Medicare Fraud
		Other Forms of Fraud
		Summary
		References
	Chapter 7: Plagiarism
		Introduction
		American Psychological Association Standards
		Types of Plagiarism
		Preventing Plagiarism
		Summary
		References
Section 3: Clinical Documentation
	Chapter 8: Client Identification (Referral and Screening)
		Introduction
		Referrals
		Role Delineation of Referrals
		Orders
		Screenings
		Role Delineation for Screenings
		Contact Note
		Summary
		References
	Chapter 9: Evaluation Reports
		Introduction
		Core Concepts of Evaluations
		Components of an Evaluation Report
		Role Delineation in the Occupational Therapy Evaluation Process
		Case: Jacob Olsen
		Writing the Report
		Re-evaluation
		Summary
		References
	Chapter 10: Goal Writing 
		Introduction
		Goal Directions
		Goal Specifics
		Summary
		References
Chapter 11: Intervention Plans
	Introduction
	Role Delineation in Intervention Planning
	Concepts for Intervention Planning
	Parts of an Intervention Plan
	Summarizing Process
	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
		Summary
		References
	Chapter 13: Discontinuation Summaries
		Introduction
		Role Delineation in Discontinuation
		Components of a Discontinuation Summary
		SOAP Format
		Summary
		References
Section 4: School System Documentation
	Chapter 14: Notice And Consent Forms
		Introduction
		Service Coordination
		Types of Notice and Consent Forms
		Summary 
		References
	Chapter 15: Individual Family Service Plan (IFSP)
		Introduction
		IFSP Requirements
		Evaluation
		Present Levels of Development
		Family Information, Resources, and Concerns
		Outcomes
		Major Outcomes
		Environmental Statement
		Starting Date and Duration of Services
		Service Coordinator
		Transition to Preschool Services
		Other Documentation
		Summary 
		References
	Chapter 16: Individual Education Program (IEP)
		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
	
Section 5: Administrative Documentation
	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
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: Medicare Standards
Appendix G: Reproducible Sample Forms
Index




Library of Congress Subject Headings for this publication: Occupational therapy Practice, Medical records, Medical protocols, Occupational Therapy methods, Medical Records standards