Documentation of paediatric assessments using the occupational therapy guidelines for client-centred practice

Although documentation is required in occupational therapy, there is little uniformity in content or format between therapists or facilities. The purpose of this article is to present a format that reflects the Canadian Guidelines for the Client-Centred approach to assessment and to share the experience of implementing this format at the Arbutus Society for Children in Victoria, British Columbia. It is hoped that client-centred documentation will facilitate role clarification, service promotion, and quality assurance. As the format reflects the conceptual framework described in the Occupational Therapy Guidelines for Client-Centred Practice (Canadian Association of Occupational Therapists, 1991b), it should be appropriate for use in other areas of practice.

Published by Canadian journal of occupational therapy. Revue canadienne d'ergotherapie, 1992. The guideline itself is at the source linked here.

doi.org/10.1177/000841749205900204