SciELO - Scientific Electronic Library Online

 
vol.46 issue1Clients' subjective experience of their participation in rehabilitation at an out-patient community rehabilitation centerAn exploratory factor analysis into the applicability of the Spirituality Care-Giving Scale, the Spirituality and Spiritual Care Rating Scale and the Spirituality in Occupational Therapy Scale to the South African context author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

Related links

  • On index processCited by Google
  • On index processSimilars in Google

Share


South African Journal of Occupational Therapy

On-line version ISSN 2310-3833
Print version ISSN 0038-2337

Abstract

BUCHANAN, Helen; JELSMA, Jennifer  and  SIEGFRIED, Nandi. Practice-based evidence: Evaluating the quality of occupational therapy patient records as evidence for practice. S. Afr. j. occup. ther. [online]. 2016, vol.46, n.1, pp.65-73. ISSN 2310-3833.  http://dx.doi.org/10.17159/2310-3833/2016/v46n1a13.

BACKGROUND: Occupational therapy patient records are required for legal purposes, but may also be used to produce evidence for practice. Our aim was to establish how comprehensively occupational therapists documented patient records. METHODOLOGY: We conducted a descriptive cross-sectional study of occupational therapists at public health facilities in a South African province. Trained raters audited five randomly-drawn records per participant using a checklist developed for the study. The maximum possible score was nine and the lowest was zero. Audits were checked for consistency. RESULTS: Forty-nine occupational therapists participated and 240 records were audited. Records contained information on intervention (96%) and changes occurring at impairment (82%) and activity and participation levels (64%). Documentation of baseline assessment (impairment level: 20%; activity and participation level: 10.4%) and re-assessment (impairment level: 7%; activity and participation level: 0.0%) was limited. Audit scores were significantly better in the work practice area (H=16.10, p=0.003) and among therapists in urban areas (U=24.50, p<0.001).There was a significant negative correlation between audit score and number of clients seen per month (rs=-0.46, p<0.001). CONCLUSION: The low audit scores suggest that the records did not contain sufficient information to produce robust evidence. Manageable ways of documenting occupational therapy practice need to be devised.

Keywords : audit; documentation; evidence-based practice; occupational therapy; patient records; practice-based evidence; quality of records.

        · text in English     · English ( pdf )

 

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License