Lundgren Pierre B. Occupational therapy as documented in patients' records -Part III. Valued but not documented. Underground practice in the context of professional written communication. Scand J Occup Ther 2001; 8: 174-183.The aim of the study was to describe some of the underground practice of occupational therapy in the context of documentation, in particular with respect to what occupational therapists (OTs) value in their daily work but not include in documentation. The study has an explorative research design comprising a quantitative content analysis of 22 records and a semi-structured interview with 11 OTs working in a geriatric clinic. Even though documentation was carried out in accordance with the occupational therapy process (as was also the case in the records the OTs felt unsatis ed with), the OTs felt dissatis ed. Whether the OTs were satis ed or not with the way they kept patient records therefore concerns other aspects besides ethical and legal ones. Focusing on occupational performance, establishing collaborative practice, co-operating in assessments and interventions and continuing a therapeutic process were domains identi ed as underground. These domains may also be expressed as steps in an occupational therapy process. The OTs were uncertain about putting words to or naming some aspects of the professional assessments, the small things going on all day long, intertwined in legitimate tools and well-de ned professional tasks, although they valued them highly.

The results developed from providing a relatively unclear and shallow perspective on OT practice to indicating a depth that shows what occupational therapy within psychiatry can be. During the process it became more and more clear how OTs think and act.

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Lundgren Pierre B, Sonn U. Occupational therapy as documented in patients' records. Part II. What is proper documentation? Contradictions and aspects of concern from the perspecti6e of OTs. Scand J Occup Ther 1999; 6: 3-10.Documentation in patients' records is one of the most important professional elements supporting interventions with clients. However, it is unclear what constitutes proper documentation among OTs. This study of 11 OTs focused on the meanings attached to the concept of proper documentation in geriatric occupational therapy. The study revealed five different contradictions that the OTs perceived within the process of providing proper documentation: contradictions between everyday language and professional language, between highly structured documentation and communicating a comprehensive picture of the patient, between juridical and ethical demands and environmental conditions, among different expectations of the various recipients of the notes and between occupational therapy reasoning and medical reasoning. These contradictions could also be described as professional dilemmas. The findings, although limited to only 11 interviews, provide insight into professional OT concerns regarding documentation, and emphasize the importance of clarifying professional language.

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