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

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

Content Provider	World Health Organization (WHO)-Global Index Medicus
Author	Backman, Annika Kåwe, Kerstin Björklund, Anita
Spatial Coverage	Sweden
Description	Country affiliation: Sweden Author Affiliation: Backman A ( Occupational Therapy Unit, Karlstad Central Hospital, Karlstad, Sweden.)
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.
File Format	HTM / HTML
ISSN	11038128
Issue Number	4
Volume Number	15
e-ISSN	16512014
Journal	Scandinavian Journal of Occupational Therapy
Language	English
Publisher	Taylor & Francis
Publisher Date	2008-12-01
Publisher Place	Great Britain (UK)
Access Restriction	Subscribed
Subject Keyword	Discipline Physical and Rehabilitation Medicine Medical Audit Medical Records Occupational Therapy Standards Humans Occupational Therapy Department, Hospital Sweden Journal Article
Content Type	Text
Resource Type	Article
Subject	Public Health, Environmental and Occupational Health Occupational Therapy

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