TY - BOOK AU - Sames,Karen M. TI - Documenting occupational therapy practice SN - 0131999486 AV - RM735.4 .S264 2010 U1 - 615.8515 22 PY - 2010/// CY - Upper Saddle River, NJ PB - Pearson Education KW - KW - Occupational therapy KW - Practice KW - Medical records KW - Medical protocols KW - Occupational Therapy KW - organization & administration KW - Medical Records KW - standards N1 - Include index; Includes bibliographical references and index; Professional communication -- Buzzwords, jargon, and abbreviations -- The occupational therapy practice framework and other documents -- Impact of models and frames of reference -- Document with care: general tips for good documentation -- Confidentiality and records retention -- Fraud -- Plagiarism -- Client identification: referral and screening -- Evaluation reports -- Goal writing -- Intervention plans -- SOAP and other methods of documenting ongoing intervention -- Discontinuation summaries -- Notice and consent forms -- Individualized family service plans -- Individualized education program -- Incident reports -- Appeal letters -- Meeting minutes -- Grant writing -- Policies and procedures -- Job descriptions ER -