The process of developing occupational therapy records: the perspective of occupational therapists

Abstract

Introduction: The Occupational Therapy Record is the document in which the occupational therapist records all client information related to the therapeutic process, from referral to the service through discharge. Objective: To identify aspects of the documentation process of the Occupational Therapy Record from the perspective of occupational therapists. Method: This was a cross-sectional, exploratory, and descriptive study. Occupational therapists actively engaged in professional practice in health care settings were included. Data were collected through an electronic questionnaire, and the data obtained were analyzed using descriptive statistics. Results: Clinical documentation in occupational therapy is considered fundamental to the development of the occupational therapist’s clinical practice and of the occupational-therapeutic process with the client. However, this activity was found to require institutional support, such as protected time and scheduling for documentation, as well as training to ensure compliance with the parameters established by official documents and practice guidelines and to improve the quality of records. Additionally, professionals described the preparation of the Occupational Therapy Record as, above all, exhausting. Conclusion: The findings highlight the need to improve the resources and time available for documentation in the Occupational Therapy Record, as well as to broaden discussion of the topic and provide further guidance on clinical documentation in occupational therapy.