Occupational Therapy as Documented in Patients Records Part III. Valued but not Documented. Underground Practice in the Context of Professional Written Communication

Abstract

The aim of the study was to describe some of the underground practice of occupational therapy in the context of documentation, in particular with respect to what occupational therapists (OTs) value in their daily work but not include in documentation. The study has an explorative research design comprising a quantitative content analysis of 22 records and a semi-structured interview with 11 OTs working in a geriatric clinic. Even though documentation was carried out in accordance with the occupational therapy process (as was also the case in the records the OTs felt unsatisfied with), the OTs felt dissatisfied. Whether the OTs were satisfied or not with the way they kept patient records therefore concerns other aspects besides ethical and legal ones. Focusing on occupational performance, establishing collaborative practice, co-operating in assessments and interventions and continuing a therapeutic process were domains identified as underground. These domains may also be expressed as steps in an occupational therapy process. The OTs were uncertain about putting words to or naming some aspects of the professional assessments, the small things going on all day long, intertwined in legitimate tools and well-defined professional tasks, although they valued them highly.

• Occupational Therapy Documentation Patient Record Professional Language Underground Practice