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Rieckmann A.1, Weber F.1, Grüneberg C.1
1Hochschule für Gesundheit, Department of Applied Health Science - Section Physiotherapy, Bochum, Germany
Background: The standards on patient records in the health care systems around the world are growing and demand efficient, transparent and well-structured resources to accomplish the requirements for professionalism, ethics and laws. A structured and accurate documentation is essential to guarantee an evidence-based and high-qualified therapy. Within the last years the documentation of therapy and especially the health reports are gaining more importance for the interprofessional communication. The German physiotherapy health report system shows inequalities within development, content and importance of therapeutic documentation. A possible explanation might be a lack of (clinical) guidelines for physiotherapeutic documentation. There is only a basic agreement existing with professional associations and the Association of Health Insurance Companies. The agreement states that the therapist should give a prognostic evaluation and prognosis towards the treatment goal and suggest possible modified proposals of the therapy plan considering to the therapeutic process.
Purpose: The aim of the study is to improve the interprofessional communication by developing a standardized patient health record system in physiotherapy with the support of a requirement analysis of physiotherapists and medical physicians.
Methods: Based on the results of a literature search on the current state of research on patient health records in physiotherapy a semi-structured interview guideline was developed. Physiotherapists of an orthopedic physical therapy outpatient clinic were asked about the current situation of health records and possible barriers and facilitators using a standardized patient health report in physiotherapy. Moreover, physiotherapists were interviewed about a presented example creating health reports with an App-Application. Afterwards we interviewed in a semi-structured telephone-interview medical doctors in private practices. All data were analyzed using content analysis (Mayring).
Results: There is a large discrepancy in the German communication between physiotherapists and medical doctors which as a result puts the patient itself in a role as the only communicator between the two professions. Physiotherapists suggest a therapy report including the results of performed assessments, demonstrated exercises and recommendations for a better and more objective evaluation of the process. The motivation writing a therapy report would be increased by a refund and doctors response. The medical doctors report a lack of information on the specific therapeutic skills and are therefore not able to take part in the adaptation of the therapeutic process. Due to the missing therapy reports as a communication device, continuous diagnostic has been done to determine the need of follow-up prescription.
Conclusion(s): The results show that a lack of communication between medical doctors and physiotherapists in Germany leading to dissatisfaction. A digital and standardized therapy report could improve the communication and health care. A mutual digital platform could be an option to improve interprofessional communication.
Implications: The determined facilitators and barriers in interprofessional communication can be improved with the help of an online platform or app-application, generating a standardized therapy report. This has to be short and simple as well as being generated directly on demand.
Funding acknowledgements: The development process of the application TheraAssist was funded by opdata GmbH.
Topic: Professional issues
Ethics approval: This research has been conducted ethically according to the principles of the Declaration of Helsinki.
All authors, affiliations and abstracts have been published as submitted.
