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Occupational Therapy

The Open Journal of Occupational Therapy

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Effectiveness Of Electronic Documentation: A Case Report, Christie Raymond, Susan Zapf, Ellen Hudgins Jul 2020

Effectiveness Of Electronic Documentation: A Case Report, Christie Raymond, Susan Zapf, Ellen Hudgins

The Open Journal of Occupational Therapy

Background: This case report aims to inform the occupational therapist and other health care professionals of documentation best practices.

Method: This qualitative case report uses an exploratory approach to compare the quality of one participant’s handwritten documentation to her electronic documentation. Outcome measures include the Accuracy Rationale Completeness (ARC) Audit to score the quality of the notes and quantity of words, and an informal discussion with the participant about her experiences using both types of documentation.

Results: The participant’s 25 handwritten notes scored a sum of 321 and the 25 electronic notes scored a …