Occupational therapy clinical report writing in South Africa – factors influencing current practice

Abstract

Introduction: Report writing is considered an essential competency for all health professionals. Current research indicates that this area of professional practice appears to be routinely neglected or poorly executed. Previous studies have aimed at understanding the reasons for this neglect; however studies specific to occupational therapy practice are lacking.

Purpose: This study aimed to explore occupational therapists’ perceptions of the factors influencing current practice in report writing within the South African context.

Method: This qualitative study included six focus group interviews with occupational therapy participants from a variety of clinical sites, fields of practice and health sectors in South Africa, with the exception of medicolegal practice. The qualitative data were inductively analysed to determine specific themes to understand the research question.

Results: While occupational therapists voiced uncertainty about ethical and legal aspects concerning report writing, certain profession-specific challenges, such as professional identity and the use of professional language, are perceived to cause a disconnect between the occupational therapists’ reporting and their clinical practice.

Conclusions: The findings of the study indicate that participants were unsure of the details regarding the legal and ethical requirements of practice for report writing and voiced both positive and some negative sentiments in terms of reflecting professional identity and profession-specific, occupation-based language, acknowledging the challenge of being in a medical setting. The complexity of writing occupational therapy reports was perceived to be influenced by the audience receiving reports, which varied widely.