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The Swedish literature shows shortcomings in the documentation of occupational therapy in patient records, especially goal setting and evaluation at discharge. Modern society has adopted the language of medicine as a framework for organizing all health service, and the law and regulations do not clearly define how to document goals, or how to record the evaluation of the interventions. Improvements are needed. Since "occupational performance" is a current concept in goal setting and evaluation of occupational therapy, the aim of this study was to obtain an understanding of how occupational performance is documented for stroke inpatients. Twenty occupational therapy records from stroke inpatients at a hospital in Sweden were analysed, using the method of constant comparison. "Occupational status" was found to be the core concept, which includes occupational performance "areas" and "aspects" assessed in pre-stroke, at admission, and at discharge. The "areas" were personal care, meal preparation, and transfer at home. The ''aspects" taken into consideration were independence, difficulty, problem related to impairment, patient contribution, safety, and physical environment. The study revealed that, as far as stroke inpatients are concerned, occupational therapists regularly documented occupational areas and assessed six aspects of occupational performance.

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