It is important to have a clear understanding of what occupational therapy reports may entail. Sames, (2009), describes three types of documentation in occupational therapy practice: the service initiation, service continuation and service termination documentation. Service initiation documentation should include an evaluation/assessment report covering factual data collected and interpretation thereof, as well as a proposed treatment plans with functional time-limited goals for the client. It should also show the need for occupational therapy service, to support financing. The continuation of the occupational therapy service documentation includes progress notes relating to continuous record keeping, which are used by many health professionals. The termination of services documentation can include a discharge summary, which highlights occupational performance at initiation and at close of intervention, along with recommendations for follow up. Reports should follow a standardised format, which is determined by each department or facility (Sames 2009).
Whilst the professional organisations in South Africa such as the HPCSA and OTASA may only offer limited guidance in the best practice of reporting on services [Health Professions Council of South Africa, 2008b; Occupational Therapy Association of South Africa, 2005], it is useful to look internationally
24 to understand how other occupational therapy organisations advise their practitioners on best practice. The American Occupational Therapy Association (AOTA) published guidelines for the documentation of occupational therapy in 2008 based on the Occupational Therapy Practice Framework: Domain and Process 2nd ed. The framework stated that the purpose of documented communication is to portray information about the client from an occupational perspective, to articulate the rationale for the provision of services and to provide a chronological record of the clients’ status, the occupational therapy service provided as well as the outcomes and response to occupational therapy [Clark and Youngstrom, 2008].
The essentials of report writing, such as the use of profession-specific guidelines, should adopt a professional style, avoid jargon, be concise but complete and should stay within the author’s area of expertise, which is supported by other experts in the field [Backman et al., 2008; Lundgren Pierre and Sonn, 1999; Pessian and Beckett, 2004]. This directive approach could serve as an effective strategy to guide therapists on how to construct their written documentation. One must consider the need to adapt the documentation to individual needs, which can be achieved only by using clinical reasoning, which is highlighted as being one of the fundamentals of reporting. Clinical reasoning is an expert skill, which assists the practitioner in understanding what is relevant and what is not [Chapparo and Ranka, 2000; Rassafiani et al., 2009].
The other fundamentals of reporting as noted by the AOTA indicate that practitioners must comply with all laws, regulations, payer and employer requirements, and that acceptable terminology should be used as defined within the boundaries of setting [Clark and Youngstrom, 2008]. These fundamentals can be seen as quite broad, highlighting that the onus of setting up specific contextual guidelines still need to be achieved within different settings. Documentation in practice must be specific to occupational therapy, which echoes the other studies highlighted above [Buchanan et al., 2016; Donaldson et al., 2004; Lundgren Pierre and Sonn, 1999; Makepeace and Zwicker, 2014].
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2.9 Conclusion
From the reviewed literature it is apparent that majority of health professionals face challenges in delivering effective reports that meet the needs of the service user, the organisation and the context, as well as the heterogeneous audiences that are the receivers of these professional reports [Bell, 1995; Donaldson et al., 2004; Harvey, 2006; Makepeace and Zwicker, 2014]. Generic issues, such as lack of resources, human and other, as well as systemic issues and ethical issues, often impact on the aim of health professional reports in meeting their true purpose of being an effective communication tool [Buchanan et al., 2016; Mlambo et al., 2004; Rischmuller and Franzsen, 2012]. These issues are obvious throughout the global context and across professions, however there are added challenges when observing this practice within the South African context. This context is plagued with additional complexities, such as limited health literacy of much of its population, a flailing health system that cannot meet the needs of the population and a population who is at risk of additional health burden through poverty [Coovadia et al., 2009; Kickbusch, 2001; McIntyre et al., 2003; McIntyre et al., 2008; Nutbeam, 2008]. Health professionals, such as occupational therapists, have a challenging time meeting the needs of the population they serve within the constraints of the organisations they work due to these challenges.
Additional to these challenges are upholding the values of the profession through how it is communicated [Wilding, 2008]. International studies have highlighted that one of the profession’s future challenges is finding and using their professional language to bring about the paradigm shift of defining occupational therapy from a medical and diagnostic perspective to an occupational perspective [Cederfeldt et al., 2003]. This requires further investigation for South African occupational therapists to enable them to communicate the occupational perspective to a population that has serious challenges with managing their health literacy [Kickbusch, 2001; Nutbeam, 2008]. The question that arises is whether occupational therapists within the South African context understand the importance of representing the identity
26 of their profession through occupational therapy reports and whether sufficient guidelines should be in place to support this area of professional practice.
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