OT terms for problems, goals, and interventions

COT has been developing national standards to support occupational therapy record keeping in electronic care records

Part of this work has been developing sets of terms that OTs routinely use in their record keeping. For example: the names of standardised assessment tools and outcome measures; and outcomes for patients / service users.

COT is developing three further sets of terms that are essential to support occupational therapy record keeping and practice, service commissioning, central returns and clinical research. These sets will be: 'Problems', 'Goals' and 'OT Interventions'.

Once completed, these three sets of terms will be incorporated into SNOMED CT, the approved clinical terminology for use in the NHS. These subsets of terms will need to be available in live NHS IT systems by late 2014, to ensure OTs can comply with the mandatory use of SNOMED from April 2015.

The project plan can be downloaded here.

There will be an online discussion forum on this website for each set of terms, to enable members to contribute to the development of these sets of OT terms. These can be found under the heading of 'General discussion'. Look for: 'Record keeping in electronic care records - "name of subset"'.

Work on the list of terms for 'Problems' is progressing. The next step is for OTs to comment on the first draft set of terms. Click here to download the document .
The request for involvement and instructions for amending and returning the list of terms can be downloaded here.