Evaluating Occupational Therapy Psychiatric Care Through Medical Documentation

Abstract

Recent JCAH survey results have reported serious deficiencies in quality assurance efforts of support departments, especially Rehabilitation Services. Because occupational therapy is grouped under Rehabilitation Services, occupational therapists should closely monitor quality assurance efforts. Quality assurance activity becomes somewhat more complex when dealing with psychiatric patients where treatment modalities lack unanimity. However, those quality assurance efforts can be more productive through better medical documentation. Medical documentation essentials are reviewed and described with an emphasis on problem oriented methods. It is proposed that adhering to these essentials will enhance professional performance as well as improve the outcome of quality assurance activities.