Keeping Records
Effective record keeping is a fundamental and important aspect of professional practice
Information on demonstrating value through the collection of data can be found within a number of RCOT resources, including this guide and template to help you demonstrate the impact of occupational therapy.
Record keeping
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 Royal 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 (April 2017 updates). Visit the NHS Digital website to access a SNOMED CT browser.
SNOMED subset standards complement the following documents:
- Professional standards for occupational therapy practice (RCOT 2017)
- Keeping records: guidance for occupational therapists (RCOT 2017)
Further information
You can find details about key areas of informatics important to the occupational therapy profession in the Royal College of Occupational Therapists’ Managing Information Strategy and Implementation Plan 2015-2025.
The Professional Record Standards Body (PRSB) is a unique collaboration of groups representing those who receive and provide health and social care across the UK, as well as those providing the IT systems that support care. The PRSB develops standards for information sharing across health and social care to facilitate better and safer care, working with the public and professionals to define the standards needed for good care records.
RCOT is a member and has been involved in developing some of the standards, and also formally endorsed most of the standards that have been produced. Access PRSB resources and find out more.