Documentation of paediatric assessments using the occupational therapy guidelines for client-centred practice

Area of Science:

• Occupational Therapy
• Client-Centred Practice
• Documentation Standards

Background:

• Occupational therapy documentation practices vary significantly in content and format across practitioners and facilities.
• There is a need for standardized documentation to ensure consistency and quality in client care.
• Existing guidelines, such as the Canadian Guidelines for the Client-Centred approach, offer a framework for improved documentation.

Observation:

• The Arbutus Society for Children in Victoria, British Columbia, implemented a new client-centred documentation format.
• This implementation aimed to align documentation with the Canadian Guidelines for Client-Centred Practice.
• The process involved adapting and applying the proposed format within a real-world clinical setting.

Findings:

• The client-centred documentation format, based on Canadian guidelines, was successfully implemented at the Arbutus Society for Children.
• This standardized approach facilitates clearer role definition for therapists.
• The format supports enhanced service promotion and robust quality assurance mechanisms.

Implications:

• Adoption of this client-centred documentation format can lead to improved consistency in occupational therapy records.
• Standardized documentation is expected to enhance communication and collaboration among healthcare professionals.
• The proposed format has the potential for broad applicability across various occupational therapy settings and practices.