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

Abstract

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.

Practice-based evidence: Evaluating the quality of occupational therapy patient records as evidence for practice

“…This may be due to occupational therapists adjusting their documentation by using medical language to be more respected in the multi-disciplinary team, and omitting the language of occupation and occupational performance 11 . In contrast to this, a second Swedish study found that although few occupational therapy records were complete, the majority captured activity and participation 37 . A United Kingdom review of the occupational therapy service within a National Health Service Trust likewise found that records focussed on activities of daily living 38 (an aspect of activity and participation).…”