Health Records: It's a Question of Orientation

Abstract

This paper challenges occupational therapists and other health professionals to become more aware of and interested in the health record. The authors argue that it is vital for health care providers to accept in practice — not just in theory — that the health record is “the focal point for quality control and accountability in patient care” and “the key document for determining standards of care.” Surveys of student and supervisor opinions are used to highlight the variation which exists in people's orientation towards health records.

Records: One Measure of Occupational Therapy Practice in the Field of Developmental Disabilities

“…Review of recent occupational therapy literature both in Australia and internationally provides limited but pertinent support of the need for documentation. Yet, as Anderson and Bell (1984) point out, "the value of the health record can be frustrated by the inability of people to recognise its purpose, its role and its usefulness in health care delivery" (p. 52). This problem is illustrated by Shah, Vanclay and Cooper (1990) whose study of stroke rehabilitation was largely based on information obtained from medical records.…”