Outcomes and Keeping Records

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 RCOT resources, including these resources to help you choose assessment and outcome measures and this guide and template to help you demonstrate the impact of occupational therapy. 

The Royal College of Occupational Therapists promotes the use of evidence-based outcome measures to demonstrate the delivery of high quality and effective occupational therapy services and to provide credible and reliable justification for the intervention that is delivered. Resources and advice on assessments and outcomes can be found on the RCOT Library Assessment and Outcome Measures page, including a Briefing on Measuring Outcomes and a Supporting Practice – Evidence and Resources (SPEaR) topic.

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.

SNOMED subset standards complement the following documents:  

Professional standards for occupational therapy practice (RCOT 2017)  
Keeping records: guidance for occupational therapists (RCOT 2017)
Standards for the structure and content of health records: Supporting occupational therapy practice and record keeping (2011)

Further information

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 Royal College of Occupational Therapists’ Managing Information Strategy and Implementation Plan 2015-2025.

The seminal documents authored by Chris Austin, Royal 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: mandy.sainty@rcot.co.uk