Documenting occupational therapy practice / Karen M. Sames.

Includes bibliographical references and index.

sect. 1. Use of language. -- Overview of the use of language in documentation -- Professional communication -- Buzzwords, jargon, and abbreviations -- The occupational therapy practice framework and important other important documents -- Impact of models and frames of reference -- Document with CARE: general tips for good documentation -- sect. 2. Ethical and legal considerations. -- Overview of ethical and legal considerations -- Confidentiality and records retention -- Fraud and abuse -- Plagiarism -- sect. 3. Clinical documentation. -- Overview of clinical documentation -- Electronic health record -- Client identification: referral and screening -- Evaluation reports -- Goal writing -- Intervention plans -- SOAP and other methods of documenting ongoing intervention -- Discharge summaries -- sect. 4. School system documentation. -- Overview of school system documentation -- Procedural safeguards: notice and consent forms -- Individualized family service plans -- Individualized education program -- sect. 5. Administrative documentation. -- Overview of administration documentation -- Incident reports -- Appeal letters -- Meeting minutes -- Grant writing -- Policies and procedures -- Job descriptions.