Occupational Status as Documented in Records for Stroke Inpatients in Sweden

Cederfeldt, Marie; Pierre, Birgitta Lundgren; Sadlo, Gaynor

doi:10.1080/11038120310009452

Cited by 8 publications

(7 citation statements)

References 5 publications

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“…The results of this study were similar to other studies examining documentation of occupational therapy intervention where the word ''difficulty'' was frequently documented during the rehabilitation process (40). The problem with clinical baselines that are immeasurable or unclear is that these outcomes do not have an objective reference point to demonstrate improvement or lack of improvement in the participants' goals.…”

Section: Discussionsupporting

confidence: 85%

Effectiveness of occupational therapy with frail community living older adults

Fisher

Atler

Potts³

2007

Scandinavian Journal of Occupational Therapy

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This study examined the effectiveness of short-term, home-based occupational therapy guided by the Occupational Therapy Intervention Process Model for improving activities of daily living [ADL] with eight frail, older adults living in assistive living. A multi-method research approach was utilized to collect both quantitative and descriptive, qualitative data in the form of a retrospective examination of the participants' clinical records. The quantitative component was a within-subjects, repeated-measures analysis of participants' Assessment of Motor and Process Skills [AMPS] ADL motor and ADL process ability measures that revealed statistically significant improvement in ADL motor, but not ADL process abilities. The qualitative component was a content analysis of the clinical records. ADL baselines, goals, interventions and outcomes documented were analyzed. Improvement was noted in 77% of the written ADL goals. Results are discussed and recommendations were given for future research and documentation to improve the profession's ability to support evidence-based practice.

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Section: Discussionsupporting

confidence: 85%

Effectiveness of occupational therapy with frail community living older adults

Fisher

Atler

Potts³

2007

Scandinavian Journal of Occupational Therapy

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“…Additionally, information belonging to different search word areas was often assembled under just one search word. In line with other studies (21,31), our study shows insufficient documentation of occupational therapy. Why is this so?…”

Section: Discussionsupporting

confidence: 84%

“…Our examination of the extent of the occupational therapy process in relation to the actual occupational therapy case showed that only one-fifth was complete compared with our prerequisites. Since the occupational therapy process is one of the quality indicators of occupational therapy (21), this result points to the fact that the documentation according to the occupational therapy cases ''Only investigation'' or ''Treatment'' could be improved.…”

Section: Discussionmentioning

confidence: 93%

“…Good documentation helps occupational therapists to communicate with other healthcare professionals and the case records are an important instrument in the process of quality, security, follow-up, and evaluation (25). Cederfelt et al (21) have shown that Swedish occupational therapy documentation in stroke patients' records, especially concerning goal-setting and evaluation in relation to discharge from hospital, have several shortcomings. The aim of this study was therefore to identify and describe how occupational therapists at a hospital in Sweden accomplished documentation of occupational therapy cases in patient case records.…”

Section: The Occupational Therapy Process Modelmentioning

confidence: 98%

“…Documentation in line with the structure of the occupational therapy process is recommended, since it contributes to increased quality (21) and meets the demand for documentation of the background for occupational therapy cases as well as the occupational therapy cases themselves (15).…”

Section: The Occupational Therapy Process Modelmentioning

confidence: 99%

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Relevance and focal view point in occupational therapists’ documentation in patient case records

Backman

Kåwe

Björklund

2008

Scandinavian Journal of Occupational Therapy

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The Code of ethics for occupational therapists stipulates how occupational therapists should think about the profession's central concepts in practice, where "Activity" and "Health" are two such concepts. Other guiding principles for practice are the Occupational Therapy Process Model and the ARTUR Case Record Structure. The aim of this study was to identify and describe how occupational therapists at a hospital in Sweden accomplished documentation of occupational therapy cases in patient case records. A stratified and random sample of one hundred occupational therapy cases was evaluated in relation to a checklist. The results showed that only 21% of the documented occupational therapy cases were complete. Often, the notes were found under the wrong keyword and 12% of the occupational therapy cases were indistinct and did not belong to any of the intervention categories in which occupational therapists normally intervene. Despite this, the majority of the documented occupational therapy cases reflected the ICF's Activity/Participation component. Our conclusion of this study is that even if not all of the occupational therapy cases documented in the patient records included all relevant information, the documentation still reflected a focus on "activity" and holistic health notions.

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Setting and Evaluating Person‐Centred Goals: An Outcome of Occupation Analysis

Park¹

2011

Occupation Analysis in Practice

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Occupational Status as Documented in Records for Stroke Inpatients in Sweden

Cited by 8 publications

References 5 publications

Effectiveness of occupational therapy with frail community living older adults

Effectiveness of occupational therapy with frail community living older adults

Relevance and focal view point in occupational therapists’ documentation in patient case records

Setting and Evaluating Person‐Centred Goals: An Outcome of Occupation Analysis

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