Presented at the Australian Association of Occupational Therapists 16th Federal Conference in Adelaide, 4–7 September, 1991.

This paper challenges occupational therapists and other health professionals to become more aware of and interested in the health record. The authors argue that it is vital for health care providers to accept in practice — not just in theory — that the health record is “the focal point for quality control and accountability in patient care” and “the key document for determining standards of care.” Surveys of student and supervisor opinions are used to highlight the variation which exists in people's orientation towards health records.

This study examined whether occupational therapists working with adult clients with developmental disabilities in New South Wales maintain client records and whether such records can be used for research purposes. A records audit was conducted to examine record format, nature of assessment, evidence of goals and client consultation in goal setting and whether legal requirements were met in the records. The findings demonstrate that New South Wales occupational therapists working in developmental disabilities maintain records for their adult clients; however, record formats vary, goals are notably absent and generally there is inconsistent data collection. The implications of these findings for using occupational therapists' records for evaluation and research are discussed.

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