Communicating evidence in clinical documentation

The purpose of this study was to examine occupational therapy practitioners' and stakeholders' opinions, perceptions, and attitudes towards communicating evidence in patient documentation. Moreover, it sought to establish relationships between factors that affect the use of evidence in documentation.

A mixed method design was used and two distinct surveys were created by the researchers in order to collect the data. In the first survey, occupational therapy practitioners in the Midwestern region of the USA completed an electronic survey. The second, a Delphi survey, was sent to other stakeholders such as case managers, rehabilitation supervisors, and payers.

There were 126 surveys returned and analysed (29% response rate). Data revealed that 63.5% of practitioners believed in communicating evidence in documentation. Clinicians of all education levels agree that practitioners should communicate the evidence when funding is at stake (χ(2) (6, N = 110) = 15.97, P = 0.014). Participants also agreed that evidence should be communicated when dictated by their department (χ(2) (2, N = 110) = 6.25, P = 0.012).