Outcomes and record keeping
Measuring and recording outcomes, and effective record keeping, are fundamental and important activities to support professional practice.
Information on outcome measures and demonstrating value through the collection of data can be found within a number of COT resources:
- Position statement - Occupational therapists’ use of standardized outcome measures
- Assessments and outcome measures - resources to help you choose assessment and outcome measures
- Supporting Practice - Evidence and Resources (SPEaR) topic - Outcomes
- DEMOnstrating the impact of occupational therapy - guide and template
- Data collection and outcomes - Taster menu
The routine use of occupational therapy terminology in record keeping is one of the essential information building blocks that can support the profession to measure, evaluate and demonstrate the effectiveness of occupational therapy interventions with service users and carers.
Electronic care records are increasingly becoming the standard means for health and social care professionals to record information about their assessments and interventions.
SNOMED Clinical Terms (CT) is a national vocabulary of clinical phrases for use within health and care systems to support the recording of information in the service user record. The College of Occupational Therapists, in collaboration with its members, has developed a number of occupational therapy subset standards. The standards should be used for all service user care records, whether they are stored digitally or on paper. They can also be used by occupational therapists when working with their local IM&T department to agree sets of coded terms for use by occupational therapists in their care records.
Occupational therapy terminology: supporting occupation-centred practice
The following documents provide some contextual information and lists of the occupational therapy subsets (October 2016 updates):
- Overview: Occupational therapy language and SNOMED CT
- Assessments used by occupational therapists
- Problems in occupational performance recorded by occupational therapists
- Goals of occupational therapy intervention
- Interventions recorded by occupational therapists
- Other useful SNOMED subsets
Visit the NHS Digital website to register for an Introduction to SNOMED CT Webinar.
SNOMED subset standards complement the following documents:
- Professional standards for occupational therapy practice (COT 2017)
- OT record keeping: using coded terms (COT Briefing 2015)
- Record Keeping (COT 2010)
- Standards for the structure and content of health records: Supporting occupational therapy practice and record keeping (2011)
You can find out more about SNOMED CT for Occupational Therapists in the College’s Professional Development Resource, and details about key areas of informatics important to the occupational therapy profession in the College of Occupational Therapists’ Managing Information Strategy and Implementation Plan 2015-2025.
By signing up to receive the monthly COTIM newsletter you can also keep up to date with occupational therapy terminology and other developments.
The seminal documents authored by Chris Austin, College of Occupational Therapists, which detail the development of the occupational therapy subsets and links with, for example, the International Classification of Functioning, Disability and Health, can be obtained by contacting: firstname.lastname@example.org