A Recording Method For Treatment Data

J. Hutchison

Occupational therapists have often been reproached for their tendency toward vagueness when reporting on a patient's condition throughout his rehabilitation program. Terms such as "poor," "fair," "almost independent," "strong," are frequently used and may tend to confuse rather than inform. Our means of evaluating condition and recording information need to be standardized, both on the qualitative and quantitative levels. Everybody is searching for a "miracle recipe," which may or may not exist. Meanwhile, in our department, we are using a method which seems to be adequate for our purposes.

Following a one-year research program on hemiplegics at the Rehabilitation Institute of Montreal, we are still using the 25 different evaluation scales that were developed by various disciplines for that research. Activities are graded on a scale from 0 to 5 (Fig. 1 ). In the Occupational Therapy Section, we use the following scales:(1) activities of daily living (ADL),(2) coordination of upper extremities,(3) endurance, (4) sitting balance, (5) standing balance, (6) functions of the upper extremities, (7) motivation, (8) home evaluation, and one that we have added more recently, (9) wheelchair independence.

At the time of a patient's discharge, a comparative report is written with regard to initial observations and results achieved. The report is easy to read, is concise, and leads to no confusion with regard to the overall picture of the patient's condition. More details are always available in our files when needed.

To compile information for either research and/or administrative purposes, we have adopted the manual punch-card system. Before such a system is started, one has to decide exactly what information will be needed. At this time, we are using the punch-card system for upper-extremity amputees only, but we intend to apply it to all conditions if it proves to be adequate. As our group of amputees (children and adults) comprise a significant treatment population, we thought they would be the best sample to use for a trial run of the recording system. With this system we can derive, for example, such information about our treatment load as the exact number of children (from 0 to 21 years), adults, congenital, traumatic, unilateral, bilateral amputees, and so on, as well as results of their functional training based on the evaluation scales used. These data give a true picture of all amputees treated in the Occupational Therapy Section.

Recording and Retrieving Methods

With the recording system, information is found in seconds. Each hole in the punch card corresponds to specific information, and it is possible to punch 336 observations on one card. The "master," or "code," card has to be made first (Fig. 2 ). All needed data are written to correspond with a number-e.g. wrist disarticulation amputation corresponds to No. 16B (upper row of holes is A, lower row is B). A questionnaire with items numbered to correspond with the code is completed by the treating therapist. All applicable observations are checked, and the secretary, using the questionnaire as a guide, punches the holes on the patient's card (Fig. 3 and Fig. 4 ).

To retrieve information, all cards are filed together, apart from the questionnaires, and a metal needle is inserted through the hole corresponding to the observation required. The cards are lifted, and those that fall provide the answer. All that remains to be done is to count them. For example, for 20 amputees treated we have compiled the following information: males, 15; females, 5; children, 11; adults, 9; left amputees, 13; right amputees, 4; bilateral amputees, 3; congenital amputees, 6; traumatic amputees, 14. ADL independency is as follows: Class 5, 15; Class 4, 2; Class 3, 2; Class 2, 0; Class 1, 1- and so on for a total of 149 observations. (Sample questionnaires and evaluation scales are available for those interested.)

As the end of a fiscal year approaches, preparing the annual report becomes a matter of minutes and can be done by a secretary, thus saving time for therapists to treat patients. This system is also invaluable for research purposes, as all observations are uniform and quantitative.

Establishing the code, or master, card is the most time-consuming job in organizing the system, and a trial run has to be made before the final questionnaire is printed, otherwise one may forget some details and realize the error only after the system is in use.

Classification and Storage

To find a card or a questionnaire easily, a number, corresponding to an alphabet code, is written on the right-hand corner of both card and questionnaire. An alphabet code is furnished with every set of cards purchased-e.g. to find Mr. B. Smith, the corresponding number is 77 in the column SMI to SOJ. All cards numbered 77 between SMI and SOJ are classified alphabetically.

At the back of each card, which is blank, the name, file number, address, and phone number of the patient, together with a short resume of the results obtained by the time of discharge, are typed by the secretary. Thus, at a glance, we have an idea of the patient's condition without having to refer to the questionnaire. For more details, we can always take out the appropriate questionnaire or complete file of the patient.

We purchase our cards from McBee Company in Montreal. For 1,500 cards and all material required, the cost is approximately $100. The form number is E91036-8 by 10-1/2 inches. The cards take very little storage space and can therefore be kept on hand at all times.

Therapists have to be meticulous about checking the right number on the questionnaire because a mistake is easily made and is time-consuming to correct.


The system described in the report may seem complex and time-consuming but it is indeed very easily organized and used by a competent staff. Our secretary manipulates all cards and compiles information in minutes. As we are the only department involved in this pilot study, it is difficult to make any positive statements as to its general applicability. However, it is easy to foresee that this method will interest other departments because of its accuracy, objectivity, easy storage of quali.-tative and quantitative information, and timesaving assets.

* The punch card system was introduced to our department in January 1967, and only new patients have a punch card. The results presented in this report were compiled from January to July 1967.

J. Hutchison is Head of Occupational Therapy Section Rehabilitation Institute of Montreal Montreal, Quebec, Canada