Occupational Therapy as Documented in Patients' Records: Part II. What is Proper Documentation? Contradictions and Aspects of Concern from the Perspective of OTs

Occupational Therapists as Street-Level Bureaucrats: Leveraging the Political Nature of Everyday Practice

Background.

As front-line service providers who often work in systems regulated by governmental bodies, occupational therapists can be conceptualized as “street-level bureaucrats” ( Lipsky, 1980/2010 ) who effect and are affected by policy.

Purpose.

Drawing on understandings from a study of long-term unemployment, this article proposes that occupational therapists, as street-level bureaucrats, respond to inter-related policies and systems in ways that can perpetuate, resist, or transform opportunities for doing and being.

Key Issues.

By highlighting practitioners’ everyday negotiation of governmental, organizational, and professional power relations, the notion of street-level bureaucracy illuminates the political nature of practice as well as the possibilities and boundaries that policy can place on ideal forms and outcomes of practice.

Implications.

Framing occupational therapists as street-level bureaucrats reinforces practitioners’ situatedness as political actors. Mobilizing this framing can enhance awareness of occupational therapists’ exercise of discretion, which can be investigated as a basis for occupation-focused and emancipatory forms of practice.

How are allied health notes used for inpatient care and clinical decision-making? A qualitative exploration of the views of doctors, nurses and allied health professionals

BACKGROUND

Inpatient care is dependent upon the effective transfer of clinical information across multiple professions. However, documented patient clinical information generated by different professions is not always successfully transferred between them. One obstacle to successful information transfer may be the reader's perception of the information, which is framed in a particular professional context, rather than the information per se.

OBJECTIVE

The aim of this research was to investigate how different health professionals perceive allied health documentation and to investigate how clinicians of all experience levels across medicine, nursing and allied health perceive and use allied health notes to inform their decision-making and treatment of patients.

METHOD

The study used a qualitative approach. A total of 53 speech pathologists, nurses, doctors, occupational therapists, dieticians and social workers (8 males; 43 females) from an Australian regional tertiary hospital participated in eleven single discipline focus groups, conducted over 4 months in 2012. Discussions were recorded and transcribed verbatim and coded into themes by content analysis.

FINDINGS

Six themes contributing to the efficacy of clinical information transference emerged from the data: day-to-day care, patient function, discharge and discharge planning, impact of busy workloads, format and structure of allied health documentation and a holistic approach to patient care.

DISCUSSION

Other professions read and used allied health notes albeit with differences in focus and need. Readers searched for specific pieces of information to answer their own questions and professional needs, in a process akin to purposive sampling. Staff used allied health notes to explore specific aspects of patient function but did not obtain a holistic picture.

CONCLUSION

Improving both the relationship between the various health professions and interpretation of other professions' documented clinical information may reduce the frequency of communication errors, thereby improving patient care.

Enhancing Professional Reasoning through the Use of Evidence-Based Assessments, Robust Case Formulations and Measurable Goals

The value of therapists documenting their clinical reasoning and negotiating specific and measurable goals is widely acknowledged. However, the literature suggests that practitioners often encounter barriers when implementing best practice.

This article details how occupational therapists in Derbyshire Healthcare NHS Foundation Trust entered an academic partnership, which transformed their communication of clinical and professional reasoning. Having adopted a conceptual model of practice, they established clearly defined processes for assessment, case formulation and goal setting. Service users, carers and team members confirmed that these initiatives enhanced person-centred practice, highlighted occupational issues and made treatment planning more effective for the whole team.

Perspectives théoriques en éducation à la santé et tenue de dossiers

Contexte. Les ergothérapeutes sont-ils impliqués en éducation et promotion de la san té comme exigé par le Code des professions du Québec? Sur le plan pratique, ils interviennent en éducation à la santé mais leur manque de référents théoriques rend difficile la reconnaissance de cet aspect de leur profession. Ainsi, les notions d'éducation à la santé se doivent d'être clarifiées. Par ailleurs, leurs interventions se reflètent-elles dans les dossiers? Objectif. Le but principal est de clarifier les notions théoriques d'éducation à la santé afin d'aider les ergothérapeutes à reconnaître les interventions qui cadrent en éducation à la santé et à les intégrer dans leurs dossiers. Défis. L'article présente l'évolution du concept d'éducation à la santé et expose les défis rencontrés lors de la documentation. Conséquences. Il propose des façons de consigner dans les dossiers et ce, en accord avec la position épistémologique sous-jacente.

Pharmacists' documentation in patients' hospital health records: issues and educational implications

Objectives

We aimed to identify potential barriers to hospital pharmacists' documentation in patients' hospital health records, and to explore pharmacists' training needs. Our objectives were to identify the methods used by pharmacists to communicate and document patient care issues, to explore pharmacists' attitudes towards documentation of patient care issues in health records, to identify and examine the factors influencing whether or not pharmacists document their care in health records and to make recommendations to inform development of a training programme to educate pharmacists regarding documentation in health records.

Methods

Methods included a questionnaire and focus groups. The study poulation was 40 clinical pharmacists in a 900-bed London teaching hospital.

Key findings

Thirty-nine pharmacists completed the questionnaire and 32 attended a focus group. Questionnaire responses indicated that 29 (74%) pharmacists did not write in patient health records; most preferred temporary notes. However, most respondents agreed that documenting their input in the health record was important. Few pharmacists believed that writing in health records would affect the doctor–pharmacist or patient–doctor relationship, or felt that health-record availability or time were barriers. Most knew when, how and which issues to document; however, most wanted more training. Focus-group discussions revealed that pharmacists feared litigation and criticism from doctors when writing in health records. Pharmacists' written communication in health records was also influenced by the perceived significance and appropriateness of clinical issues, pharmacists' acceptance by doctors, and pharmacists' ‘ownership’ of the health record.

Conclusions

While recognising the importance of documenting relevant issues in health records, pharmacists rarely did so in practice and preferred to use oral communication or temporary adhesive notes instead. Pharmacists need to overcome their fear of criticism and litigation in order to document more appropriately in health records. A trust policy and training may offer pharmacists a sense of protection, enabling more confident documentation in patients' health records.

Occupational therapists’ reflection on practice within psychiatric care: A Delphi study

AIM

The aim of this study was to describe the reflections on practice in a group of Swedish occupational therapists in psychiatric care in order to illuminate the present practice and ideas about the future using a Delphi survey of three rounds.

MATERIAL AND METHOD

The sample consisted of 14 occupational therapists in psychiatric care. The answers from the first and second rounds illustrate the wide variation in their practice. The third round points out consensus and disagreements in the domains: professional role, theories in practice, domain of concern, occupational therapy assessment, goal setting/treatment, outcome/evaluation and thoughts about the future. A consensus was reached in all domains, but not regarding competence to treat functional reduction and symptoms, or on the importance of theories for documentation, the choice of a theoretical foundation, and the importance of an evidence-based treatment model, although the theories were seen as supporting practice. Disagreements were found as to the effectiveness of repeated assessments as a means of evaluation. The future for OTs within psychiatric care was looked upon as positive.

DISCUSSION

The results developed from providing a relatively unclear and shallow perspective on OT practice to indicating a depth that shows what occupational therapy within psychiatry can be. During the process it became more and more clear how OTs think and act.