Jäppinen A-M1
1Helsinki University Hospital, Internal Medicine and Rehabilitation, Helsinki, Finland
Background: Adequate documentation is a part of safe and best possible health care and rehabilitation. Documentation in physiotherapy in Finland is regulated by laws, instructions of Ministry of Social Affairs and Health and instructions of Finnish Physiotherapy Association. The hospital/employer makes the local instructions in the base of national directions suitable for local patient record system. The demand for standard, structural format of patients' records is inevitable not only for the continuity of care and rehabilitation, but also to store records in the Patient Data Repository.
Purpose: The aim of this study was to evaluate the structure of electronic health records in physiotherapy and how the local instructions of physiotherapy documentation were followed. This study was made in collaboration with physiotherapist and their managers in order to develop physiotherapy documentation and its' instructions.
Methods: In this survey study contact physiotherapists, responsible for developing documentation, evaluated the structure of health records made by physiotherapists in their own unit. The evaluation questionnaire was made in the basis of local instructions of physiotherapy documentation in the health care district. The questionnaire was internet based and included 44 questions, which were mainly claims with yes/no answer alternatives and open questions to clarify answers. The anonymity of physiotherapists and patients were ensured. The survey was carried out in 2017.
Results: The data consisted of 136 answers of 136 physiotherapy health records. In 93 % (n=127) health records physiotherapists used structural format. In health records following headlines and information were most described: the reason for care (71%, n=97), diagnosis (62%, n=85), patients' ability to manage in activities of daily living (53 %, n=74), patient education/counselling (70 %, n=95), physiotherapy/rehabilitation services (72 %, n=98), the continuity of care or physiotherapy services (74%, n=100). The following content were less described: the environmental factors of patient (29%, n=40), physiotherapeutic assessment results (43 %, n=57), conclusions from assessment (24%, n=33).
Conclusion(s): Physiotherapists used structural format in their documentation. Many relevant and important information could be found in health records in same structure. Still important information was lacking, for example conclusions from physiotherapeutic assessment, which could be considered important result from clinical reasoning.
Implications: The results of this study have been used and can be used in developing documentation instructions and standards. New Customer and Patient Record System, which combines social and health care services in the health care district, will be adopted during 2018-2020. The new system enables better structural format of documentation, the use of ICF and The National Classification of Physiotherapy Practice.
Keywords: Physiotherapy, documentation, health record
Funding acknowledgements: No funding
Purpose: The aim of this study was to evaluate the structure of electronic health records in physiotherapy and how the local instructions of physiotherapy documentation were followed. This study was made in collaboration with physiotherapist and their managers in order to develop physiotherapy documentation and its' instructions.
Methods: In this survey study contact physiotherapists, responsible for developing documentation, evaluated the structure of health records made by physiotherapists in their own unit. The evaluation questionnaire was made in the basis of local instructions of physiotherapy documentation in the health care district. The questionnaire was internet based and included 44 questions, which were mainly claims with yes/no answer alternatives and open questions to clarify answers. The anonymity of physiotherapists and patients were ensured. The survey was carried out in 2017.
Results: The data consisted of 136 answers of 136 physiotherapy health records. In 93 % (n=127) health records physiotherapists used structural format. In health records following headlines and information were most described: the reason for care (71%, n=97), diagnosis (62%, n=85), patients' ability to manage in activities of daily living (53 %, n=74), patient education/counselling (70 %, n=95), physiotherapy/rehabilitation services (72 %, n=98), the continuity of care or physiotherapy services (74%, n=100). The following content were less described: the environmental factors of patient (29%, n=40), physiotherapeutic assessment results (43 %, n=57), conclusions from assessment (24%, n=33).
Conclusion(s): Physiotherapists used structural format in their documentation. Many relevant and important information could be found in health records in same structure. Still important information was lacking, for example conclusions from physiotherapeutic assessment, which could be considered important result from clinical reasoning.
Implications: The results of this study have been used and can be used in developing documentation instructions and standards. New Customer and Patient Record System, which combines social and health care services in the health care district, will be adopted during 2018-2020. The new system enables better structural format of documentation, the use of ICF and The National Classification of Physiotherapy Practice.
Keywords: Physiotherapy, documentation, health record
Funding acknowledgements: No funding
Topic: Information management, technology & big data; Professional practice: other
Ethics approval required: No
Institution: N/A
Ethics committee: N/A
Reason not required: The study was a patient record study with no identification of patients. It was a part of normal quality assessment work.
All authors, affiliations and abstracts have been published as submitted.
