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

• The Code of Ethics for Occupational Therapists stipulates how occupational therapists should think about the profession’s central concepts in practice, where ‘Health’ is one such concept. Other guiding principles for practice are the Occupational Therapy Process Model and the ARTUR Case Record Structure. The aim of this study has been to identify and describe how occupational therapists at a hospital in Sweden documented interventions in patient case records. A stratified and random sample of one hundred case records was evaluated in relation to a checklist. The results showed that only 21 percent of the case records were complete. Often, the notes were found under the wrong keyword and 12 percent 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 case records reflected the ICF’s Activity/Participation component, which could be interpreted to mean that the occupational therapists held holistic health notions in line with the code of ethics. In order to improve the occupational therapists’ documentation in patient case records, further discussions of the central concepts and guiding principles for occupational therapy are required.

Ämnesord

MEDICIN OCH HÄLSOVETENSKAP  -- Hälsovetenskap -- Arbetsterapi (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Health Sciences -- Occupational Therapy (hsv//eng)

Nyckelord

Activity/participation

ARTUR

body function/structure

goal formulation

health concept

ICF

occupational therapy process.

Occupational therapy

Arbetsterapi

Publikations- och innehållstyp

ref (ämneskategori)

art (ämneskategori)