Principles of Documentation

Catalog description

An overview of essential professional and occupational-specific terminology to promote efficient and accurate documentation of occupational therapy services. This course will provide an overview of personal and professional responsibilities related to liability issues. Building off of professional responsibilities, students will also be exposed to the purpose of documentation as well as legal and ethical issues in documentation. Students will be introduced to reporting evaluation data, creating intervention plans, documenting progress notes, and establishing discharge summaries. An introduction to the consultative process with persons, groups, programs, organizations, or communities will be presented. The impact of occupational therapy services on the healthcare team and how to communicate using accepted terminology with members of the interprofessional team will be presented. Emphasis will be placed on electronic documentation systems, virtual therapeutic environments, and the delivery of occupational therapy services using telehealth technology. Prerequisite: Successful completion of the previous semester.