Documentation quality in occupational therapy patient records: Focusing on the technical aid prescription process

In order to plan for and implement research on the outcome of the technical aid prescription process, more knowledge about the documentation of the process is imperative. The overarching aim of this study was to survey documentation quality aspects in patient records in community-based OT, with a particular focus on the technical aid prescription process. An additional aim was to compare the quality of patient record documentation in two municipalities with different documentation routines. The study was accomplished in two Swedish municipalities. By means of an extensive, structured survey protocol, 182 community OT patient records were examined, covering a two-year period. The comparison between two municipalities with different kinds of documentation routines demonstrated differences but as neither of them showed higher documentation quality there was no clear evidence that either of them is superior to the other. In conclusion, the results of this study show a considerable need for quality development in occupational therapy documentation, targeting documentation in general but also concerning the specific aspect of documenting the technical aid prescription process