Assessing the quality of clinical occupational therapy records kept at schools for learners with special educational needs in the Western Cape

Abstract

iv Abstract This research report compares what occupational therapists working at schools for learners with special educational needs (LSEN) think is important to record with what is recorded in the learners' occupational therapy files. Six clinical occupational therapists completed a questionnaire by grading items according to their level of importance in maintaining occupational therapy records. The researcher did an audit on 76 learners' occupational therapy files at four LSEN schools. The results indicated a vast discrepancy between what the occupational therapist viewed as important and what was actually recorded in the learners' files. The occupational therapists viewed most items as being very important to record (84.2%), yet the items were seldom recorded in the learners' files (33.3%). The researcher used the results to develop an adjusted checklist that could be used by occupational therapists at LSEN schools to audit their own records and as a guideline for record keeping.