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Relevance and focal view point in occupational therapists' documentation in patient case records
Jönköping University, School of Health Science, HHJ, Dep. of Rehabilitation. Jönköping University, School of Health Science, HHJ. Quality improvements, innovations and leadership in health care and social work.
2008 (English)In: Scandinavian Journal of Occupational Therapy, ISSN 1103-8128, E-ISSN 1651-2014, Vol. 15, no 4, p. 212-220Article in journal (Refereed) Published
Abstract [en]

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.

Place, publisher, year, edition, pages
2008. Vol. 15, no 4, p. 212-220
Keyword [en]
Activity/participation, ARTUR, body function/structure, goal formulation, health concept, ICF, occupational therapy process.
National Category
Occupational Therapy
Identifiers
URN: urn:nbn:se:hj:diva-6206DOI: 10.1080/11038120802087626OAI: oai:DiVA.org:hj-6206DiVA, id: diva2:37026
Available from: 2008-11-27 Created: 2008-11-27 Last updated: 2017-12-12Bibliographically approved

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Backman, AnnikaKåwe, KerstinBjörklund, Anita

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CiteExportLink to record
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Citation style
  • apa
  • harvard1
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
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  • nn-NO
  • nn-NB
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  • Other locale
More languages
Output format
  • html
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  • asciidoc
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