Practice-based evidence: evaluating the quality of occupational therapy patient records as evidence for practice

Background: Occupational therapy patient records are required for legal purposes, but may also be used to produce evidence for practice. Our aim was to establish how comprehensively occupational therapists documented patient records. Methods: We conducted a descriptive cross-sectional study of occupational therapists at public health facilities in a South African province. Trained raters audited five randomly-drawn records per participant using a checklist developed for the study. The maximum possible score was nine and the lowest was zero. Audits were checked for consistency. Results: Forty-nine occupational therapists participated and 240 records were audited. Records contained information on intervention (96%) and changes occurring at impairment (82%) and activity and participation levels (64%). Documentation of baseline assessment (impairment level: 20%; activity and participation level: 10.4%) and re-assessment (impairment level: 7%; activity and participation level: 0.0%) was limited. Audit scores were significantly better in the work practice area (H=16.10, p=0.003) and among therapists in urban areas (U=24.50, p<0.001).There was a significant negative correlation between audit score and number of clients seen per month (rs=-0.46, p<0.001). Conclusion: The low audit scores suggest that the records did not contain sufficient information to produce robust evidence. Manageable ways of documenting occupational therapy practice need to be devised. Key words: audit, documentation, evidence-based practice, occupational therapy, patient records, practice-based evidence, quality of records