OT record headings

Standards for the Structure and Content of Health Records: Supporting Occupational Therapy Practice and Record Keeping

 
This online resource describes the OT headings project and lists the headings that have been developed by the College of Occupational Therapists for use in all electronic care records. The record headings will ensure that all electronic care record systems can be designed to support occupational therapy record keeping and practice.
 
The use of OT headings will improve consistency in record keeping resulting in improved data quality. These improvements are essential if service user information recorded by OTs is to be used for secondary purposes, e.g. service commissioning, central returns, clinical audit and OT research.
 
Download OT Record Headings