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Medical Record Documentation: The Quality Of Physiotherapy Entries, Anna Phillips, Kathy Stiller, Marie Williams
Medical Record Documentation: The Quality Of Physiotherapy Entries, Anna Phillips, Kathy Stiller, Marie Williams
Internet Journal of Allied Health Sciences and Practice
This study evaluated the standard of in-patient medical record documentation by physiotherapists at the Royal Adelaide Hospital (RAH), Adelaide, South Australia, during 2003. The impact of patient characteristics (ie primary diagnosis and length of stay in hospital) and physiotherapist features (eg employment classification level and years of employment at the RAH) on the standard of documentation was also explored. One hundred medical records were randomly selected for review and 224 physiotherapy entries were audited. The audit tool was based on the RAH Physiotherapy Department Guidelines for Documentation, which was comprised of five sections. Each section contained several items, which were …