Medical record: reflections on documental quality in occupational therapy
DOI:
https://doi.org/10.11606/issn.2238-6149.v30i2p110-115Keywords:
Records, Occupational therapy, Documentation, Forms and records control, StandardsAbstract
The records of occupational therapy aim to describe the therapeutic process, making explicit the critical thinking, professional reasoning and decision making of the occupational therapist. However, the importance of record goes beyond the scope of care, since these notes are also used in the administrative, educational and scientific context. But is the performance of this procedure performed with quality by occupational therapists? Aiming to discuss the theme, the authors will present informations on the quality of the records, based on a reflexive analysis guided by the profession’s guidelines on documentation. As main datas, the presence of inconsistencies in the documentary practice of occupational therapists were evidenced, factor is related to the lack of knowledge of the guidelines of the profession, the difficulties with the technical language and the process of initial and continued training. Therefore, it is recommended to expand and deepen researches on the tematic, to obtain more effective educational strategies and systematization of more manageable records models.
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References
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