Document Detail

Relevance and focal view point in occupational therapists' documentation in patient case records.
MedLine Citation:
PMID:  18609245     Owner:  NLM     Status:  MEDLINE    
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.
Annika Backman; Kerstin Kåwe; Anita Björklund
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Scandinavian journal of occupational therapy     Volume:  15     ISSN:  1103-8128     ISO Abbreviation:  Scand J Occup Ther     Publication Date:  2008 Dec 
Date Detail:
Created Date:  2008-11-25     Completed Date:  2009-04-10     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  9502210     Medline TA:  Scand J Occup Ther     Country:  Norway    
Other Details:
Languages:  eng     Pagination:  212-20     Citation Subset:  IM    
Occupational Therapy Unit, Karlstad Central Hospital, Karlstad, Sweden.
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MeSH Terms
Medical Audit*
Medical Records*
Occupational Therapy / standards*
Occupational Therapy Department, Hospital

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