Retrospective Chart Audit of Three Occupational Therapy Cases

Abstract

This paper reviews a report in which three charts were audited retrospectively by a registered nurse for the purpose of assessing occupational therapy services and record keeping in a nursing home. The audit revealed improvement in patient function, excellent documentation and communication, and that despite evidenced need for continued treatment, cost beyond Medicare coverage was problematic to patients and families. Review revealed that while the auditor misinterpreted occupational therapy terminology in the audit analysis, conclusions were not altered substantially. This paper indicates that evaluation of comprehensive documentation can demonstrate the effectiveness of occupational therapy.