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Record Keeping in Occupational Therapy: Are We Meeting the Standards set by

the College of Occupational Therapists?

Article in British Journal of Occupational Therapy · December 2004

DOI: 10.1177/030802260406701205

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Practice Evaluation

Occupational therapists from a range of specialties 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.

Record Keeping in Occupational Therapy:

Are We Meeting the Standards set by the
College of Occupational Therapists?
Fiona Gibson, Michael Sykes and Sue Young

Introduction part of a more general ward audit and, therefore, provided

little information on the quality of records. Phaneuf (1976)
The College of Occupational Therapists sets standards for developed a tool for use by nurses, supervisors and
practice, which define a level of proficiency and form the administrators for quality control; however, questions were
basis of service evaluation (COT 2000a). The importance of raised regarding the reliability and validity of the tool
the records that occupational therapists keep to document (Manfredi 1986, Corben 1997).
professional interventions, the advice given and the outcome More relevant is an audit of occupational therapy records
of decisions taken are highlighted within these standards by Anderson et al (1991) against the Australian Council on
(COT 2000b). The core standard on record keeping relates Healthcare Standards. This identified that 48% of therapists
to the content, access, confidentiality, storage and disposal kept records for all clients, with 68% including an
of records (COT 2000c) and includes a recommendation that assessment; 23% recorded goals of intervention, 64% met
record keeping is audited, a process that can be defined as: the legal requirements and 10% showed evidence of client
or carer involvement. The study was limited by the small
Systematically looking at the procedures used for diagnosis,
sample group (121 records from 23 therapists).
care and treatment, examining how associated resources are
The present study aimed to take account of this criticism
used and investigated the effect care has on the outcome of
when auditing the records of occupational therapists against
quality of life (Department of Health 1998, pXX).
the standards outlined by their professional body. It also
The practitioners within Tayside were keen to identify aimed to provide a more contemporaneous assessment of
where their record keeping met the required standard and to the documentation of a broader population of occupational
identify, prioritise and action methods of improving practice therapists.
where standards were not being met.

Method
Literature review
A retrospective case note audit tool was developed using the
A literature search on record keeping was carried out using standards set by the COT on record keeping. The tool
the Medline and CINAHL electronic databases, identifying enabled the occupational therapists in Tayside to audit
98 relevant articles. Over half of these focused on nursing against 61 out of these 92 standards. It was not possible to
systems. The majority of the articles described the audit all the standards set by the COT using this method;
responsibilities of the health professional and the for example, standard 4.2 states ‘The occupational therapy
consequences of inadequate record keeping. There was a department has a copy of the employing organisation’s
paucity of literature relating to the audit of records. Corben policy on storage, transfer and disposal of records, and this
(1997) highlighted that documentation was often audited as is complied with at all times’.

British Journal of Occupational Therapy December 2004 67(12) 1

 The audit tool also differed from the COT tool by Fig. 1. Ease of locating items: audit results against COT
including ‘Not applicable’ as a possible response. This standards 1.3, 2.2 and 2.4.
ensured that those responding ‘Not met’ to a standard felt The following could be easily located
that that particular standard did indeed relate to them in Yes No Not applicable
their particular place of work and with their client group.
Views of clients/carers
In this way, the audit tool both increased the validity of the
Names of family/carers
responses and enabled local discussion as to whether the
standards did indeed apply to their area of work. It is to be Name of professional

noted, however, that by omitting this option the COT Discharge reports

implied that all the standards set were applicable to all Progress records
occupational therapists. Treatment/programme plans
The tool was piloted in four different areas, representing
Goals located
a geographical and specialism spread across Tayside.
Assessments
Following the piloting stage, the tool was amended and a
Relevant history
guidance sheet developed to ensure that each of the
standards was interpreted in a uniform manner. This was 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

further encouraged by presentations to occupational

therapists, across each of the specialisms in NHS Tayside,
The difficulty in locating the views of clients and carers
including rehabilitation, care of elderly people, acute,
within the records is notable given the fresh impetus provided
learning disabilities, mental health and paediatrics. At each
to patient involvement by The New NHS: Modern, Dependable
location, the occupational therapists agreed to audit each
(Department of Health 1997). This need to focus upon the
other’s documentation. This was necessary because of the
client is highlighted by the COT (2000b) in its Code of Ethics
nature of some of the standards, for example, the legibility
and Professional Conduct for Occupational Therapists:
of handwriting.
Five sets of notes were audited by each occupational Each client is unique and, therefore, brings an individual
therapist involved. Case records were randomly sampled to perspective to the occupational therapy process. Normally,
identify three current and two discharged clients. Where an clients have a right to make choices and decisions about their
occupational therapist had not discharged any clients in the own health and independence, and such choices should be
previous 3 months, two further current clients were respected even when in conflict with professional opinion
randomly selected. The small sample size of case notes per (section 2.1.1).
occupational therapist was necessary owing to the length of
It is difficult to see how compliance with the code of ethics
time, on average 45 minutes, needed to audit one case note.
can be demonstrated without evidence of the views of
The audit form was then completed and the results analysed
clients and carers within the client record.
anonymously by Tayside Audit Resource for Primary Care.
An anonymised overall report was returned to each of the
Assessments, goals and interventions
six Heads of Service, who also received an anonymised
The data recorded on assessments, goals and interventions
report relating purely to the combined staff under their line
were examined in more detail (COT standards 2.5, 2.6 and
management. Individual therapists were offered the
2.7), as shown in Fig. 2. The assessments were usually
opportunity to have their forms returned directly to them.
reported clearly and logically, including the method of
assessment and the findings. The recording of treatment
goals was more variable, with 57% of goals being written
Results and discussion without time scales or review dates and 56% not documenting
the client’s knowledge and agreement of the goals set. Of the
Sixty-four out of the 82 occupational therapists in Tayside
goals that were not achieved, 36% had no explanation of the
were able to complete the audit of five clients’ records,
reasons for non-achievement. The outlines of the interventions
giving a response rate of 78% or 320 client records.
were clearly documented, with 78% of interventions clearly
relating to a specific problem. The outcome of each
Ease of locating items
intervention was recorded in 84% of the notes.
The first set of criteria within the audit dealt with the ease of
The findings mirror those of Anderson et al (1991),
locating items within the records (COT standards 1.3, 2.2 and
whose audit identified the absence of recorded client goals.
2.4). Fig. 1 shows that the relevant histories, assessments
The finding that intervention outcomes were recorded but
and progress records were usually easy to locate. It was more
did not relate to any treatment goals provides evidence that
difficult to locate goals of intervention and treatment plans.
occupational therapists are not adhering to the Code of Ethics
Most records clearly included the name of the professional
and Professional Conduct for Occupational Therapists (COT
working with the patient. The details of family members or
2000b), which states:
carers were difficult to locate in 18% of the records. In 35%
of the records, it was difficult to locate documentation of the Every client should have a clearly recorded assessment of need
views of the client and his or her carers. and objectives of treatment/intervention (section 3.3.4).

2 British Journal of Occupational Therapy December 2004 67(12)

Fig. 2. Assessments, goals and interventions: audit results Fig. 4. Use of language: audit results against COT standard 1.5.
against COT standards 2.5, 2.6 and 2.7.
Yes No Not applicable
Yes No Not applicable

Abbreviations/acronyms used in
Assessment methods reported in full continuation sheets are explained

Assessment findings reported in full

Abbreviations/acronyms used in
Clients’ knowledge and agreement of reports are explained
goal recorded

Time scales and review dates specified

Goals not achieved recorded with reasons Slang/colloquialisms are not used
for non-achievement

Interventions clearly and logically outlined 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Corresponding problem outlined

The standards also state that the client or a non-health/social

Outcome of intervention outlined
care professional should be able to understand the language
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
used in the record (standard 3.3). The results demonstrated
that the therapists identified that this group could not
understand 18% of the records sampled. However, it must
Discharge reports containing overviews be kept in mind that the auditors were occupational
As 73% of the records were current files, there were a therapists who may not be as objective in their assessment of
smaller number of discharge reports to include in the audit this standard as a client or non-health/social care
(88 records). Fig. 3 indicates that of this smaller sample, professional. The finding that abbreviations and acronyms
40% identified that it was ‘not applicable’ to include overviews were not explained in 63% of the records supports this
on outcomes, treatment, aims, problems and assessments, as assertion. This has therefore become a key area for the
specified within the COT standards 2.5, 2.6 and 2.7. therapists to target because any improvement in this will
have an impact on two standards.
Fig. 3. Discharge reports contain overviews: audit results against
COT standard 2.11. Staff entries
Yes No Not applicable Fig. 5 shows that the occupational therapist’s signature was
legible on 82% of occasions and that the author’s job title
Outcomes
appeared in 61% of the records. Standards 1.8 and 1.9 state
Treatment that student entries should be countersigned (which was
done in 20% of the records), as should those of support staff
Aims
(8%). The need to countersign the entries of the latter staff
Problems group can, according to the COT, be subject to a local
Assessments
policy.

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Fig. 5. Staff entries: audit results against COT standards 1.7,
1.8 and 1.9.

Use of language Yes No Not applicable

The standards state that abbreviations and acronyms should be

Support staff entries countersigned
explained in full the first time that they are used in occupational
therapy records (standard 1.5); Fig. 4 identifies that in 63% Student entries countersigned
of the records this was found not to be the case. Similarly,
28% of the records met the standard by not using slang and Author’s job title written
colloquialisms. However, in 37% of the records the therapists
identified that it was not applicable to exclude slang and Signature legible
colloquialisms from the record. This could be due to the
standard stating that the record should include the views of 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
client and carers. Anecdotal evidence from therapists working
in the field of learning disabilities suggests that clients’ views
are often reported in the records in the clients’ own words, Action plans
which may include colloquialisms or local dialects. It cannot From the audit results, individual departments devised their
be said, therefore that therapists are solely responsible for own action plans, based on their own priorities. Examples of
the use of slang and colloquialisms in the records. the recommendations include:

British Journal of Occupational Therapy December 2004 67(12) 3

 ■ Local policies to be devised on countersigning of support The additional benefit to occupational therapists in
staff records auditing their records regularly is that when they know that
■ Revision of departmental standardised documentation they are meeting the standards, the records can then be used
■ Education on writing in clients’ records to audit successfully other aspects of future practice.
■ In-service training on goal setting and action planning
■ Auditing against the remaining COT record keeping Acknowledgements
standards. The authors would like to thank the occupational therapists who took part
In addition to this, the learning from this project has in the audit, including the Heads of Service; clinical governance for
been shared through submission on the Clinical providing funding; the Community Workshop for photocopying the audit
Improvement Projects (CLIP) database, presentation at a forms; and Frances Fairweather, Russel Ayling and Tayside Audit Resource
national conference and posters at a variety of conferences. for Primary Care.

References
Conclusion Anderson B, Llewellyn G, Bell J (1991) Records: one measure of
occupational therapy practice in the field of developmental disabilities.
This audit has described how occupational therapists in Australian Occupational Therapy Journal, 38(2), 77-81.
Tayside are currently meeting the COT’s (2000c) standards College of Occupational Therapists (2000a) Members first. London: COT.
on record keeping. The authors have no reason to think that College of Occupational Therapists (2000b) Code of ethics and
the way in which therapists are recording their practice in professional conduct for occupational therapists. London: COT.
Tayside is any different from that in other health board College of Occupational Therapists (2000c) Occupational therapy record
authority areas. However, the lack of recent published keeping. Core standard. Standards for Practice SP002. London: COT.
evidence in the audit of occupational therapy record keeping Corben V (1997) The Buckinghamshire nursing record audit tool: a unique
is noted. approach to documentation. Journal of Nursing Management, 5(5),
The results of the first audit cycle show that the audit 289-93.
tool was successful in identifying both the areas of good Creek J (2003) Occupational therapy defined as a complex intervention.
practice to be celebrated and the areas requiring some London: COT.
changes in current practice. The findings have been fed back Department of Health (1997) The New NHS: modern, dependable.
to the service managers, with an offer of facilitation to London: HMSO.
develop and implement local action plans ahead of the Department of Health (1998) A first class service: quality in the NHS.
second audit cycle. London: HMSO.
The results have also highlighted issues for further Manfredi C (1986) Reliability and validity of the Phaneuf nursing audit.
debate. First, there is the issue of the appropriateness of Western Journal of Nursing Research, 8, 168-80.
some of the standards given that the occupational therapists Phaneuf MC (1976) The nursing audit – self-regulation in practice. 2nd ed.
considered that certain standard areas were not applicable to New York: Appleton Century Crofts.
their practice. Secondly, there is the question of how the
local challenges of improving therapists’ ability to set and Authors
record goals and interventions with client involvement are to Fiona Gibson, BScOT, Senior Occupational Therapist.
be overcome. It is hoped that by doing this, occupational Michael Sykes, BSc(Hons), DipN, Clinical Audit Facilitator.
therapy will be able to build upon the way it currently Sue Young, BScOT, Senior Occupational Therapist, Tayside Audit Resource
documents professional interventions, advice given and the for Primary Care, Tayside Centre for General Practice, Kirsty Semple
outcome of decisions taken. Way, Dundee DD2 4BJ. Email: fiona.l.gibson@tpct.scot.nhs.uk

4 British Journal of Occupational Therapy December 2004 67(12)

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