Documentation of Paediatric Assessments using the Occupational Therapy Guidelines for Client-Centred Practice

Although documentation is required in occupational therapy, there is little uniformity in content or format between therapists or facilities. The purpose of this article is to present a format that reflects the Canadian Guidelines for the Client-Centred approach to assessment and to share the experience of implementing this format at the Arbutus Society for Children in Victoria, British Columbia. It is hoped that client-centred documentation will facilitate role clarification, service promotion, and quality assurance. As the format reflects the conceptual framework described in the Occupational Therapy Guidelines for Client-Centred Practice (Canadian Association of Occupational Therapists, 1991b), it should be appropriate for use in other areas of practice.