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Occupational therapy sequential client care recording system: a comparative study.

L A Llorens, J J Shuster

    The American Journal of Occupational Therapy : Official Publication of the American Occupational Therapy Association
    |July 1, 1977
    PubMed
    Summary
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    A new occupational therapy client care record system, combining the Developmental Analysis, Evaluation and Intervention Schedule and Problem Oriented Medical Record, proved more effective than traditional methods. This enhanced system improved record completeness, organization, understandability, and usefulness.

    Area of Science:

    • Occupational Therapy
    • Health Informatics
    • Clinical Documentation

    Background:

    • Client care records are crucial for establishing occupational therapy standards of care.
    • Existing traditional records may not fully meet the demands of comprehensive client management.
    • Integrating theoretical frameworks with scientific methods can enhance clinical documentation.

    Purpose of the Study:

    • To evaluate the effectiveness of a novel client care recording system in occupational therapy.
    • To compare a combined Developmental Analysis, Evaluation and Intervention Schedule (DAIS) and Problem Oriented Medical Record (POMR) system against traditional records.

    Main Methods:

    • A research form of the client care record was developed, integrating DAIS and POMR.
    • This new system was compared to a traditional client care record.

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  • An interdisciplinary panel assessed both record forms on completeness, organization, understandability, and usefulness.

    • Main Results:

    • Statistically significant differences were found between the novel and traditional client care record systems.
    • The combined DAIS-POMR system demonstrated superior performance in key assessment variables.

    Conclusions:

    • The integrated client care record system (DAIS-POMR) is more effective than traditional systems.
    • This enhanced system offers improvements in occupational therapy documentation and client care standards.