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NZAOT Medical Staffing International Achievement Award 2003

The work of a Waitakere-based OT striving to present 'person-centered', rather than 'illness-centred' information through clinical notes, has been recognised with the 2cal Staffing International Achievement Award.

Heleen Blijlevens, BHSc(OT), PGDipHSc(Occupational Science) spent more than two years working on a project with Juanita Murphy to improve the efficiency, accuracy and relevance ofcord notes in medical files.

"As clinicians we write in medical files," she explains. "But the structures that we tended to use were very medical-oriented, and tended to focus on problems and diagn than areas that OT's cuence."

This documentation structure was commonly referred t 'SOAP notes' - or Sub-Objective-Assessment Plan.

In her research article titled "Washing away SOAP notes: Refreshing clinical documentation," Heleen notes that the structure previously used by therapists was grounded in a general problem solving approach, and enabled readers to quickly gain an understanding of the client's physical functioning in activities normally performed within a service setting. However this format lacked occupational history or information about their greater home env as community and proximity to services.

Heleen and Juanita researched the issue by investigating two models, including the World Health Organization's Classification of Functioning, Disalth, and the Canadianof Occupational Performance.

The end result was a format for OTs to write in clinical notes. "It started off more like an interview format," she explains. "Now it includes progress notes, and discha when people leave the service." Their article says that documenting practice in occupational terms will break barriers and refocus clinical reasoning processes on an enabling a view that recognises tmportance of occupatiomeans and ends for practice.

The new client-centered note writing framework includes facilities to document important social and lifestyle factors such as the Home (including terrain, distance to letterbox, community), Social and Cultural Environment (such as family, values, siblings, spirituality), and Occupational Performance (sleeping, eating, finances, shopping, hobbies). Client's goals and intervention strategies also recorded, understood and mo more effectively.

Heleen and Juanita presented their findings a conference this year and word has spread.

Her methodologies have created interest from Middlemore, Palmerston North, and are now documentation policy at Waitakere and North Shore hospitals, for both inpatient and community departments, and when Heleen presented at an Asia-Pacific Congress, her work received sign interest from well known overseas OT's.

Clare Hocking, Principal Lecturer at AUT, nominated Heleen for the Inaugural Award, which recognises innovative service delivery or contribution to practice. In the nomination form Clare says that Heleen's work represents a redevelopment of things the profession has always done. Clare says that the developments revealed by Heleen will increase the profile of occupational therapy because the rationale for intervention priorities and the relevance of occupational will be made more evidclinical records.

In Heleen's research article she states that the framework she introduces is intended to provide a means for therapists to display the profession's unique perspay that others reading will understand.

"This framework could be utilised in all areas of occupational therapy practice," she says. "I would like to see it get used by other district health boards. The challenge now is to develop a user friendly computerised template, as well as enhancing it to be utilised by acute therapy services where there is often greater emphasis on impairment based interventions."

Heleen, who is from Christchurch, spent two years studying Chemical and Process Engineering at Canterbury University before she realised that instead of working with 'pipes and processes', she wanted to be with people and do practical things. She finished her OT study in Auckland in 1997, worked for a private hospital group as sole OT for a period, and has spent the last four years with Waitemata. Her interests lie in neuro rehab - she began her Masters, which looks at dyspraxia after stroke and how people experience that in their everyday lives, three years ago and aims to finish it within the next year. Heleen is currently seconded to Waitakere Outreach, where she will work until February doing hom rehab for people with neurological conditions.

Heleen was presented with her Award certificate and $1000 voucher by Medical Staffing's Kirsten Thomforde, the NZAOT President Jane Wilsxecutive Siobhan Molloy at AUT on 20 November 2003. H put the funds towardsr research and development.

To find out more about the NZAOT Medical Staffing International Achievement Award watch Insight for updates. Sometime in the New Year updates will also be available on /www.nzaot.com and on this web page. Heleen can be contacted at Heleen.bns@waitematadhb.govt.nz.

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