South African Journal of Occupational Therapy
versão On-line ISSN 0038-2337
RISCHMULLER, Renee e FRANZSEN, Denise. Assessment of record keeping at schools for learners with special educational needs in the Western Cape. S. Afr. j. occup. ther. [online]. 2012, vol.42, n.2, pp. 13-20. ISSN 0038-2337.
This study investigated occupational therapy record keeping at schools for learners with special educational needs (LSEN). A review of the records in the form of an audit on 76 occupational therapy files at four LSEN schools was completed using a checklist designed for the purpose of the research. Except for the general section on record keeping in the audit most of the information on the checklist was recorded less than 50% of the time in the learners' files. A number of factors including the roles and expectations of occupational therapists at the schools and a lack of clear guidelines from the Western Cape Education Department as to what should be recorded were found to influence record keeping. The quality of record keeping in terms of access, storage and retrieval was also considered. A redesigned checklist was drawn up to assist occupational therapists at LSEN schools to audit their records and to use as a guideline for improving the quality of the record keeping.
Palavras-chave : LSEN Schools; Record keeping; Checklist; Audit.