Record Keeping in Occupational Therapy: Are We Meeting the Standards set by the College of Occupational Therapists?

Abstract

Sixty-four occupational therapists from a range of specialisms in Tayside audited 320 client records against 61 standards from the College of Occupational Therapists' core standard on record keeping. The audit found that there were areas to be celebrated, such as the inclusion of relevant client history and the outcome of interventions. The challenges identified included documenting the views of clients, the recording of treatment goals and the use of abbreviations. The conclusions focused on client involvement, the occupational therapy process and the appropriateness of the College of Occupational Therapists' standards.