Occupational Therapists Chart a Course through the Health Record

Abstract

The absence of clear and practical guidelines for documenting on the health record often makes charting a disorganized and unsatisfying experience for occupational therapists. Like the health record, the occupational therapy process is structured to reflect a problem solving process that promotes clinical reasoning. The model described in this paper was developed to reflect the occupational therapy process as identified in the Occupational Therapy Guidelines for Client-centred Practice and proposes an additional section on problem naming. It is viewed as an open loop through which the client may move one or more times while learning to cope with change until enough momentum is gathered to move into adaptation. Emphasis is placed on naming and validating each problem with the client, and negotiating responsibilities and expected outcomes. This feedback loop summarizes the steps required to practice occupational therapy from a client-centred stance. Occupational therapists who develop competence in using this model, chart in an organized, client-centred, and therefore more satisfying manner.