By Karen M. Sames MBA OTR/L

A accomplished advisor to making potent documentation in occupational therapy.


Documenting Occupational remedy Practice, 3/e is the main finished textual content on occupational remedy documentation at present out there, overlaying basic documentation rules, scientific documentation, digital documentation, tuition approach documentation, and documentation of administrative projects. greater than only a how-to guide, the textual content explores vital moral, criminal, and language concerns concerning documentation as well as proposing step by step ideas for developing profitable cleaning soap notes, communications, and documentation. The 3rd version has been totally up-to-date to mirror present AOTA legitimate files and new digital documentation instruments, and has been reorganized to enhance clarity. powerful evaluate instruments aid readers actually grasp documentation strategies and techniques, whereas the text’s accompanying site presents extra studying assets that may be accessed at the go.


Teaching and studying Experience


This textual content deals a complete advisor to making potent documentation for occupational remedy. It provides:

  • Comprehensive assurance of all components of practice: Chapters research the underlying suggestions of fine documentation in scientific, institution, and administrative settings.
  • Practical innovations and techniques that arrange scholars for the workplace: Chapters current transparent, potent techniques for drafting documentation and communique that may be without delay utilized in specialist settings.
  • Exploration of moral and felony matters: Discussions aid scholars know the way documentation impacts others and supply problem-solving thoughts for addressing felony and moral concerns.
  • Coverage of digital documentation: Screenshots and dialogue of digital overall healthiness list (EHR) structures familiarize scholars with present documentation applied sciences.
  • Effective studying tools: evaluate routines and various reference instruments aid scholars actually grasp textual content material.

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Boston, MA: Jones and Bartlett. Sherwood, K. D. ). Context. html Terry, M. (2008). Text messaging in healthcare: The elephant knocking at the door. Telemedicine Journal and E-Health: The Official Journal of the American Telemedicine ­Association, 14, 520–524. 8495 The ARC. (2012) What is people first language? org/page. , & … Sinclair, L. (2008). Effectiveness of an adapted SBAR communication tool for a rehabilitation setting. ), 72–79. com. (2010). Formal and informal writing. ). Netiquette.

SO return demonstration not adequate. Will need additional instruction. Here is the same paragraph written in relatively plain English: Patient participated in a 45-minute bedside session this morning for self-care activities. The pt. sat at the edge of the bed with minimal assistance. With minimal assistance following setup, the patient washed his face and trunk, brushed his teeth, and combed his hair. He did not wash his L arm or the L side of his face. The pt’s wife was instructed in ways to set up tasks and verbally cue the patient to compensate for left visual field cut.

S: B: A: R: 10 Chapter 2: Professional Communication 2. To physician: A client who missed his last two appointments comes to the clinic at a time other than his scheduled appointment, slurring his speech, and he does not remember how he got there. S: B: A: R: 3. To teacher: A child you are working with has improved by leaps and bounds. She is now tying her shoes independently, writing her name legibly, and engaging in ageappropriate play. S: B: A: R: 4. To OT supervisor: A client has had a tendon transfer and needs a specific splint.

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