CJOT VOLUME 59 NO 2

DIANE WATSON

Documentation of paediatric assessments using the occupational therapy guidelines for client-centred practice

KEY WORDS Assessment process, occupational therapy Client-centred practice, occupational therapy Documentation Paediatrics

ABSTRACT

Although documentation is required in occupational therapy,

there is little uniformity in content or format between therapists or facilities. The purpose of this a rticle 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.

RSUM

Bien que la tenue de dossier soit ncessaire en ergothrapie,

il se retrouve peu d'uniformit quant au contenu et au format utiliss par diffrents ergothrapeutes er diffrents milieux de pratique. Cet article veut prsenter un format qui reflte l'approche des Lignes directrices relatives la
Diane Watson B.Sc.O.T., OT (C) was a clinical therapist at the Arbutus Society for Children. She is presently enrolled in the Masters of Business Administration programme at the University of Western Ontario in London, Ontario. Correspondence address: Box 25, Site 471, R.R. 4, Sherwood Park, Alberta, T8A 3K4.

pratique de l'ergothrapie axe sur le client en ce qui a trait l'valuation afin d'appliquer ce format au sein de la "Arbutus Society for Children" Victoria en Colombie-Britanique. Il est esprer que la tenue de dossier axe sur le client permettra de clarifier les rles, de mettre en lumire l'apport de l'ergothrapie et d'amliorer la garantie de la qualit. Ce format en accord avec le cadre conceptuel dcrit dans les Lignes directrices relatives la pratique de l'ergothrapie axe sur le client (MSNBS et ACE, 1983) pourrait tre utilis dans d'autres domaines de pratique.

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The Guidelines for the Client-Centred Practice of Occupational Therapy (Department of National Health and Welfare & Canadian Association of Occupational Therapists (DNHW & CAOT, 1983), recently published as Occupational Therapy Guidelines for Client-centred Practice (Canadian Association of Occupational Therapists (CAOT), 1991b), which will be referred to as the Guidelines in this article, suggest that assessment information might be listed under headings for occupational performance and performance components (CAOT, 1991). The purpose of this a rt icle is to propose a documentation format that reflects this approach and to share the experience of implementating this format within the Physical Medicine Department at the Arbutus Society for Children in Victoria, British Columbia. The assessment document communicates factual information to the client, family, team members, referral source and other community agents. It provides data for treatment planning, education, research, reimbursement for disability benefits, programme evaluation and promotion and quality assurance (Allen, Foto, Moon-Sperling, & Wilson, 1989; Kuntavash, 1987). "The reporting of raw data, rather than its analysis within a frame of reference is not acceptable practice" (Gill & Brockett, 1987, pg. 54). Although documentation is required, there is little uniformity in content or format between therapists or facilities. Review of assessment documents collected from across Canada suggest that paediatric therapists tend to provide detailed assessments of occupational performance components based on many informal and standardized assessment tools. These reports all too often do not include basic information on self-care, productivity and leisure or indicate how performance components effect daily living skills. The Guidelines indicate that a "global assessment should include evaluation and documentation of the individual's abilities and deficits in occupational performance, performance components, and environmental areas" (CAOT, 1991b, pg 27 & 28). In 1990, the occupational therapists at the Arbutus Society for Children established a committee to review their documentation format and develop a s ty le that would better reflect these guidelines and the se rv ice being offered. A recent publication by Stewa rt and Ha rv ey (1990), Application of the Guidelines for Client-Centred Practice to Paediatric Occupational Therapy, and the receipt of Stewa rt and Harvey's unpublished information inspired the committee to proceed. The publication of Uniform Terminology for Occupational Therapy - Second Edition (American Occupational Therapy Association (AOTA), 1989) and Application of Uniform Terminology to Practice (Dunn & McGourty, 1989) provided a great deal of direction, clarity and enthusiasm. The Canadian Association of Occupational Therapists' Position Paper on the Role of Occupational
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Therapy in Paediatrics, which will be referred to as the Position Paper (CAOT, 1991a), and inservice sessions at the Universi ty Hospital in Vancouver, British Columbia on Occupational Therapy Diagnosis (Fearing, 1991) were instrumental in cementing our views and improving the language in our reports. By combining the recommendations from the above resources and directives, the occupational therapists at the Arbutus Society have developed a client-centred format for paediatric assessment documentation.

DOCUMENTATION USING THE CLIENT-CENTRED MODEL

The Assessment Report I. Introduction: The introduction identifies the referral source, reason and date. The medical diagnoses, information referenced from other professionals, relevant history and precautions are included. Clinical interpretations, such as paralysis, are discussed under assessment. Confidentiality of this information must he considered. II. Assessment: Information describing the source and method of data collection is provided. Sources include: the client, family, community agencies or other team members. Methods include: inte rv iew, observation, questionnaires, standardized testing, and performance checklists (AOTA, 1989; CAOT, 1991b). A. Occupational Performance (Daily Living Skills) Health is maintained through engagement in a flexible balance of self-care, productive and leisure activities, which develop and change throughout the life span (CAOT, 1991a; CAOT, 1991h). The child's ability to meet developmental role expectations is assessed and documented first. Only outcome behaviours are described. Component skills and environmental factors that effect performance are described in the "B" assessment section, and the link between daily living skills and component skills and environmental factors are described in the interpretation section. Self-Care: Self-care includes activities or tasks that are done routinely to maintain health and well-being in the environment (Reed & Sanderson, 1980). Performance in grooming, hygiene, mobility, dressing, feeding, mealtime planning, toileting and community living skills is documented in the Guidelines (CAOT, 1991b). Uniform terminology for occupational therapy (AOTA, 1989) includes: functional communication, sexual expression, and socialization. In infancy, the self-care occupation relates to the ability to perform or participate. In childhood, transition from a dependent to an independent role should

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be discussed. In adolescence, independence in home responsibilities and community mobility become important. Access to public services, transpo rt ation and community resources is also expected and should be documented. Depending on the repo rt reader, a statement describing the expected role given the developmental stage or age may be helpful. Productivity: Productivity includes activities or tasks that are done to enable a person to provide suppo rt to the self, family and society through the production of goods and services (CAOT, 1991b; Reed & Sanderson, 1980). Willard and Spackman (1983) describe productive activities as the life roles that are recognized by the social environment and are pa rt of one's role identity. It covers the activities and roles that give meaning and purpose to life (CAOT, 1991b). Stewa rt and Harvey (1990) suggest that there is a developmental connection between play and work and that paediatric therapists address play to prepare children to be productive adults. The Guidelines include the activities of: play, school work, paid work, volunteer work and home making. Play can be described in terms of skill competencies, interest, aptitudes and developmental stage (CAOT, 1991b). Uniform Terminology for Occupational Therapy (AOTA, 1989) includes: educational activities, vocational exploration, job acquisition and work experience. At the Arbutus Socie ty , it was useful and educational for the assessment repo rt reader to begin this section with a brief statement as to the productive role expected of the client given their disability and chronological age. The following phrases were developed at the Arbutus Socie ty for use in the assessment repo rt s, from the concepts expressed in the CAOT Position Paper: Occupational Therapy in Schools (CAOT, 1990). These phrases include: `The productive role of infancy is to learn through movement, play and engagement in the environment.', `The productive role in early childhood is to engage in and learn from exploration and activity engagement. The primary occupation is the productive student role.', `The productive role of adolescence is to a tt end school, prepare for future vocational pursuits, achieve independence from parents, explore roles, establish a personal identity and integrate these developmental challenges.' Leisure: Leisure includes the components of life that are free from work and self-care and includes the activities or tasks done for enjoyment and renewal (Reed & Sanderson, 1980). The leisure occupations include: play preferences, hobbies, social involvement, entertainment, use of free time, cultural interests, recreation, sports involvement, volunteering etc. (CAOT, 1991b). In infancy, children explore through play and demonstrate playtime preferences. In childhood, children are exploring leisure interests, developing friend-

ships outside of the family and becoming more involved in community activities and play times. In adolescence, children are actively pursuing, exploring and developing leisure interests, and social networks. Leisure can be assessed and documented in terms of interests, aptitudes, skills and frequency of involvement (CAOT, 1991b). B. Performance Components and Environmental Factors that Effect Daily Living Rogers (1983), the Guidelines (CAOT, 1991b) and the CAOT Position Paper: Occupational Therapy in Schools (CAOT, 1990) all recommend that therapists assess and document abilities and deficits to construct a fair and valid image of the client and develop an appreciation of the interdependence of emerging skills. As our treatment is designed to help individuals enhance abilities and remediate disabilities, an assessment must include an evaluation of assets and liabilities by documenting performance components (CAOT, 1991b). This section should only include components and factors. The interpretation section will describe their impact on daily living. Performance components are defined as "skills and abilities that the individual uses to engage in the performance areas" (Dunn & McGourty, 1989, pg. 817). These components include the mental, physical, spiritual and socio-cultural self. Environmental factors `outside' the individual include the social, cultural and physical environment (CAOT, 1991b). In summary, an individual's ability or potential to engage in occupational activities is a culmination of components `within' the individual and environmental factors `outside' the individual. The individual is affected by and can effect these components and factors (CAOT, 1991b). The Position Paper (CAOT, 1991a), suggests that paediatric performance components include motor, sensory integrative, cognitive, psychological and social domains. These components enable the child to engage in adaptive behaviours which lay the foundation for occupational role development. The proposed format taken from the Position Paper (1991a) and the Guidelines (1991b) (Figure 1) integrates these models by categorizing the different performance components and environmental factors into four areas: interpersonal, intrapersonal, physical and environmental. Given that the classification of performance components varies among the Position Paper(1991a), the Guidelines (1991b), the American Association of Occupational Therapy's Uniform Terminology (1989) and other conceptual models of practice (Reed & Sanderson, 1980) the committee chose category names that were conceptually broad, yet relatively simple. Interpersonal: In paediatric occupational therapy, the family is recognized as the primary therapeutic
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Figure 1 Integrating the Model of Occupattional Performance in Children and the Client-centred Practice Model of Occupational Therapy into Four Areas of Documentation

motor

integrative

cognitive

psychological

social

IS FROM FRIEFELD, PHILLIPS AND SNIDER (C.J.O.T., 1991)

INTERPERSONAL

INTRAPERSONAL

PHYSICAL

ENVIRONMENTAL

Environment (social, physical, cultural)

spiritual

physical

The Individual

mental

PERFORMANCE COMPONENTS A AREAS OF OCCUPATIONAL PERFORMANCE INTERACTING ELEMENTS OF THE INDIVIDUAL IN A MODEL OF OCCUPATIONAL PERFORMANCE: THE CLIENT CENTRED MODEL ADAPTED FROM REED AND SANDERSON (1980)

Repnoduccd with permissionophe Ministry of Sum* and Services Canada(/991).

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agent. Family members and community caregivers are responsible for sharing in the child's programme to the best of their ability. The repo rt should acknowledge this family and community perspective by including information related to the socio-cultural component and social environmental factor described in the Guidelines and the Position Paper. The socio-cultural component describes the interpersonal relationships with reference to family, education, ethnic and community background. Family relationships, beliefs and values, social support systems, friendships, community involvement, goals and priorities, interpersonal skills, and social conduct are outlined (CAOT, 1991b). intrapersonal: This section identifies the priority treatment goals from the child's perspective and covers the mental and spiritual components described in the Guidelines (1991b) and cognitive and psychological domains described in the Position Paper (1991a). The mental component encompasses cognition (memory, orientation, insight, problem solving, sequencing, concept formation, generalization, integration and synthesis of learning and perception), affect (appropriateness, behaviour control, thought content, body image, self image, self control, and coping skills) and volition (CAOT, 1991b; AOTA, 1989). The spiritual component describes the individual's sense of self, purpose and control and source of inner motivation. It is the internal and external factors that "influence individuals in defining their own meaning of independence, interdependence and power in their lives" (CAOT, 1991b, pg viii). This spiritual component is "one of the fundamental elements in conceptualizing Canadian occupational therapy practice" and is addressed in this section (CAOT, 1991b, pg 18). The term intrapersonal was derived from the work of Reed and Sanderson (1980) and was chosen due to the sensitivity around using the terms mental, spiritual, cognitive or psychological for repo rt headings. As intrapersonal is not a colloquial term, this section follows the interpersonal section to provide a frame of reference for the reader. Physical: The physical (orthopaedic, neuromuscular) component described in the Guidelines (CAOT, 1991b) and the motor and sensory integrative domains described in the Position Paper (1991a) are documented next. Orthopaedic status includes information on range of motion, strength, pain, soft tissue integrity and deformities. Neuromuscular data includes tone, endurance and reflex activity. Sensory motor competencies include postural stability, fine and gross motor competencies, coordination, midline control, activity tolerance, bilateral integration, praxis etc. (AOTA, 1989; CAOT, 1991b).

Environmental: This section includes the physical and cultural elements of the environment that impact performance and the `setting' in which daily living skills are performed (CAOT, 1991b). Physical and cultural environmental factors may positively or negatively effect function. Issues around environmental accessibility, adaptive equipment, orthotic appliances and classroom or home milieu are described. Cultural issues include interests in others, attitudes, remedies or approaches towards sickness/disability, expectations regarding work, leadership in the family, roles, behaviour, and activities requiring pa rticipation for acceptance (CAOT, 1991b). III. Interpretation Occupational therapists demonstrate their unique contribution to health assessment by interpreting or diagnosing how abilities and limitations in performance components and environmental factors effect the individual's functional outcome in occupational performance areas (Dunn & McGourty, 1989; CAOT, 1991b). The interpretive section begins with a summary of the introduction section with reference to the child's ability to engage in occupational performance or daily living areas. Performance components and/or environmental factors that positively and negatively impact specific occupational therapy areas are described. A statement about which specific components or factors need to be addressed to facilitate occupational engagement is given and prognostic statements that use clinical judgement can be included. IV. Goals If the purpose of therapy is to develop skills, restore function, maintain ability and prevent dysfunction and maladaptive behaviours (CAOT, 1991b), goals need to include these key words. Goals should include a statement of desired change in occupational performance, be specific, measurable and realistic and include a review date. The method by which performance components or environmental factors are addressed is documented in the se rvice plan on the cha rt , rather than the assessment repo rt . V. Recommendations The treatment plan should describe whether treatment will be directed toward remediating functional skills, building foundation skills and/or adapting the environment (CAOT, 1991a). The recommended se rvice (treatment, consultation, monitor or review) is stated. The recommended intensity and approach to intervention is detailed on the cha rt , rather than the assessment report.

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IMPLEMENTATION OF THE FORMAT AT THE ARBUTUS SOCIETY FOR CHILDREN

This format has been tried for 1 year at the Arbutus Society for Children, a multi-facility organization employing 21 occupational therapists. Therapists are assigned to 15 programmes at three separate facilities: G.R. Pearkes Centre for Children, Queen Alexandra Hospital for Children and Jack Ledger Child and Adolescent Psychiatric Unit. The department se rv es approximately 800 children with minimal to severe physical and/or psychiatric challenges through inpatient, outpatient and outreach se rv ices. Once a documentation committee established an initial format style, staff training began. A questionnaire survey conducted by the Canadian Association of Occupational Therapists (CAOT, 1991b) in 1987 found that 14 % of 156 occupational therapists answered not at all' and only 6 % answered 'know them extremely well' when asked how knowledgable they were about the Guidelines. Meetings to teach and review how documentation could reflect our client-centred practice were held on a weekly basis for two months. All staff assisted in applying the format to different services. A peer review system was established by therapists requesting assistance. During the process a number of points became evident: e Initial assessment repo rt s are more time consuming for the experienced writer, but documentation time and report length return to previous levels after four to six practice trials. This format is more time efficient for the new therapist and student. e Documentation now provides an opportunity for therapists and students to refine their skills in relating component skills and deficits to function. Delineating goals and treatment priorities become obvious once the assessment information is categorized. Experience and practice among staff fostered confidence in articulating the role of therapy and treatment goals in multidisciplinary conferences. e The three occupational performance and four performance components and environmental factors are areas of mandatory documentation for therapists in both physical medicine and psychiatry. Although many therapists tend to want to eliminate sections due to lack of information, a comprehensive assessment must include information in all areas. e Performance components can be presented in various orders to reflect the child or the purpose of the assessment. e Assessment report readers have commented that these reports provide a more holistic picture of the

child. The repo rt s communicate more clearly to the health care consumer the reason why occupational therapy is recommended, for what duration and the strategy for intervention (CAOT, 1991b). Beginning paragraphs with topic sentences is an easier method of organizing the data for the reader than point form or further sub-divisions. For example, the paragraphs under self-care could begin 'During meal times, ...', 'Hygienically, ...'. Underlining the titles of standardized tests referenced within the document text is another method of quick reference. e Combining physiotherapy and occupational therapy assessments has shown good results. Screening service is more time efficient. By screening competencies in occupational performance, the necessity for further assessment of performance components and environmental factors can be determined (CAOT, 1991b). If occupational dysfunction is identified, only then are components evaluated (Stewart & Ha rv ey, 1990). If a child has performance component problems but no corresponding occupational performance deficit, occupational therapy intervention is not proposed (Dunn & McGourty, 1989). e The data collected with this format provide the information needed to measure the impact of treating components and environmental factors. When documentation only included information on components, evidence of change in occupational performance was not available. Although the Arbutus Society therapists are just now experimenting with the format of progress notes, documentation of change in occupational performance seems to be a reasonable and popular approach. The Guidelines suggest that discharge documents include functional status, goal attainment and plans for ongoing se rv ices or recommendations (CAOT, 1991b).

CONCLUSION
Over the last decade, occupational therapists have defined and refined the client-centred model of assessment and treatment. Although there are no clear guidelines for documentation, an assessment repo rt shouldrefctvianpomeurcti. The client-centred profile reflects occupational therapists' contribution to the health assessment and validates the need to address performance and environmental components to develop, restore or maintain occupational engagement and prevent dysfunction. Client-centred documentation has helped the occupational therapists at the Arbutus Socie ty for Children to produce comprehensive assessment reports and streamline referrals. As this format reflects the conceptual framework described in the Guidelines, it should be appropriate for use in other areas of practice.

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CASE EXAMPLE
L Introduction AB is a 4 year 6 month old girl who was referred to occupational therapy for assessment by her paediatrician, following her relocation to Victoria. AB has a lumbar meningomyelocele and shunted hydrocephalus. An ophthalmologist, follows AB on a yearly basis. Physiotherapy is currently assessing. II. Assessment This assessment was compiled with information gathered through parent and daycare staff interview, questionaire, clinical observation and standardized testing. A. Occupational Performance (Daily Living Skills) Self-Care: Childhood is a time when AB is learning the skills to gain independence in self-care. AB is able to feed herself independently with a spoon or fork. She is on intermittant catheterization, which her mother does. AB requires assistance to take all garments on and off and manage clothing fasteners. She baths and brushes her teeth with parental supervision, but requires no assistance for hand and face washing. AB is mobile in her wheelchair at home and in her neighbourhood. She is independent for bed and couch transfers, but requires assistance on and off the toilet and in and out of the tub. Productivity: In early childhood, AB's productive role is to engage in and learn from activity exploration and engagement. AB attends a half-day daycare programme three days a week. She is unable to attend her local daycare, due to "accessibility problems" which her mother is "working on". Her daycare case manager indicates that AB "is very chatty and distractible", "likes to watch rather than participate" and "doesn't like a rt ". At play school, she likes basketball and playing hockey. She is able to access the slide, but little other playground equipment. At home AB has a variety of favorite toys that she plays with "constantly". Leisure: AB enjoys watching movies with her brother and would like to learn to swim with him. She is "active with the neighborhood kids" and has a "number of friends at daycare and two best friends" next door.

She lives with her 3 year old brother and parents. Mom is interested in AB developing more independence in self-care. Intrapersonal: AB indicates that she enjoys her daycare but would like to go to playschool with her two best friends that live next door. During testing, AB was very talkative, self distracting and her average task attention span was less than 5 minutes. AB labelled all primary colours, rote counted to 20 and counted objects to 3. She was unable to complete a form board, or match colours/objects that were the same. Her performance on the Motor-Free Visual Perceptual Test was much below the average. Physical: Vision and hearing monitored by Spina Bifida Clinic. Right esotrophia monitored by Dr. E. AB lacks all sensation below L4 and has a number of bruises on her legs. Above L4, her sensation sensitivity and discrimination appear within normal limits. AB has fu ll functional upper and lower extremity range of motion and no orthopedic problems that effect function. She has a small lumbar gibbus that is free of irritation. Trunk and upper extremity tone is hypotonic and lower limbs flaccid. AB is able to sit independently and is mobile on the floor by commando crawling. Excellent trunk control and upper limb strength. She uses her wheelchair safely and efficiently for community mobility. Fine motor skills, as assessed with the Peabody Developmental Motor Scales (Fine Motor Index), are much below average. She is right dominant and uses both hands together for play. She demonstrates normal movement patterns but they are immature and of poor quality. A pincher grasp and isolated finger control is present and manipulation of small objects within her hand is only emerging. AB holds a pencil with a pronated palmar grasp and scribbles pictures. On the

Beery Developmental Test of Visual Motor Integration (Revised), AB's reproduction of figure drawings with
pencil on paper was much below the average. Although, she imitates lines and circles, she is unable to draw any recognizable form or person. Environmental: AB's current daycare and home are accessible. Her home community daycare has six stairs at the entrance, but is accessible inside. The playground equipment, except the slide, at the current daycare is inaccessible due to a 30 centimetre high step perimeter. The local swimming pool where AB would like to take lessons is wheelchair accessible, but AB has no means of getting from her wheelchair into the water independently. AB currently wears ankle foot orthoses during the day. She has a one year old C & D wheelchair that is in good order. Interpretation AB is a 4 1/2 year old girl with a lumbar meningomyelocele and shunted hydrocephalus who was as-

B. Performance Components or Environmental Factors that Effect Daily Living Interpersonal: AB is described as a "sensitive", "social and chatty" girl who has lots of friends. She prefers solitary play at home and cooperative small group activities at her daycare. In group, she likes to assume a leadership role and direct the activities of her friends.

III.

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sessed at the Spina Bifida Clinic following her family's relocation to Victoria. Although AB plays an active role in self care, productive and leisure activities, her level of independence and pa rt icipation is not in keeping with her chronological age peers or her personal and family expectations. Her mother's and her own desires for enhanced pa rt icipation are attainable goals. Although AB has achieved some independence in her self-care skills, she requires assistance to learn self catheterization and dressing. AB has developed friendships and play opportunities at home and daycare, but she would like to access her home community programmes and swimming pool. She has learned many pre-academic concepts, but her perceptual and visual motor abilities appear below average and result in her preference to "watch", "dislike" a rt , and delayed drawing skills. She is "chatty and distractible" and I wonder how this will eventually impact her classroom etiquette.

Canadian Occupational Therapy Association. (1991a). Position paper on the role of occupational therapy in paediatrics.
Canadian Journal of Occupational Therapy, 58.

centrefold. Canadian Occupational Therapy Association. (1991b). Occupational Therapy Guidelines for Client-centred Practice.

Toronto, ON: CAOT Publications. Department of National Health and Welfare & Canadian Association of Occupational Therapists. (1983). Guidelines
for the Client-Centred Practice of Occupational Therapy.

IV. Goals
Develop dressing skills to take garments on and off and manage large buttons on an overcoat. Develop independence in personal hygiene by learning self catheterization and transfers in and out of the bathtub and on and off the toilet. Prevent further skin damage by learning precautions and proper care of lower limbs. Develop visual perceptual motor skills to draw a recognizable picture and participate in all a rt activities. Develop community network and leisure skills to maintain neighbourhood friendships by making the local daycare and swimming pool accessible.

Ottawa, ON: Department of National Health and Welfare. Department of National Health and Welfare and the Canadian Association of Occupational Therapists. (1987). Toward Outcome Measures in Occupational Therapy. Ottawa, ON: Department of National Health and Welfare. Dunn, W. & McGourty, L., (1989). Application of uniform terminology to practice. American Journal of Occupational Therapy, 40, 830-832. Gi ll , T. & Brockett, M. (1987) The guidelines for the clientcentred practice of occupational therapy: The basis for practice in Canada. Canadian Journal of Occupational Therapy, 54, 53-54. Fearing, V. (1991, January). Occupational Therapy Diagnoses. University of British Columbia, Vancouver, B.C. Kuntavanish, A., (1987). Occupational Therapy Documentation. Rockville, MA: American Occupational Therapy Association. Reed, K. & Sanderson, S. (1980). Concepts of Occupational Therapy. Baltimore: Williams & Wilkins. Rogers, J.C. (1983). Clinical reasoning: The ethics, science and art. American Journal of Occupational Therapy, 37, 601-616. Stewart, D. & Ha rv ey, S. (1990). Application of the guidelines for client-centred practice to paediatric occupational therapy. Canadian Journal of Occupational Therapy, 57,
88-94.

V. Recommendations
1. Provide sho rt term treatment to build perceptual motor skills and teach transfers, dressing and self catheterization techniques. Occupational therapy should provide consultation service to community agencies and AB's family regarding environmental adaptations for wheelchair accessibility and equipment for bathroom independence. 2. A referral to a Speech and Language Pathologist will be made requesting an assessment to determine if there is a potential language basis to AB's "chatty and distractible" behaviours.

Hopkins H. & Smith H. (eds.) (1983). Willard & Spackman Occupational Therapy (6th Edition). Philadelphia: J.B. Lippincott. AUTHOR'S NOTE
Although the initial work and first draft of this article was completed before the publication of the 1991 edition of Occupational Therapy Guidelines for ClientCentred Practice (CAOT, 1991b), these new Guidelines have been referenced throughout the text. The original three volumes of the Guidelines, published by the Department of National Health and Welfare and the Canadian Association of Occupational Therapists in 1983, 1986, and 1987, were used to develop this assessment documentation format. These editions are updated and reprinted in the 1991 edition.

REFERENCES Allen, C., Foto, M., Moon-Sperling, T. & Wilson, D. (1989). A medical review approach to medicare outpatient documentation. American Journal of Occupational Therapy, 43, 793-800. American Occupational Therapy Association. (1989). Uniform terminology for occupational therapy (2nd Edition). American Journal of Occupational Therapy, 43, 808-815. Canadian Association of Occupational Therapists. (1990). Position paper on occupational therapy in schools.
Canadian Journal of Occupational Therapy, 54, centrefold.
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ACKNOWLEDGEMENTS
The author would like to acknowledge Karen Litchfield, Mary Witoski and the occupational therapists at the Arbutus Socie ty for sharing their views and assisting in the development of this documentation format. I am also thankful to Phyllis Straathoff, Jan Mason and the Arbutus Society's administrative support of this project.