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Full-Text Articles in Medicine and Health Sciences
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 …
Electronic Clinical Records For Physiotherapists, Christine Barry, Mark Jones, Karen Grimmer
Electronic Clinical Records For Physiotherapists, Christine Barry, Mark Jones, Karen Grimmer
Internet Journal of Allied Health Sciences and Practice
Purpose: This pilot study compared traditional (paper-based) and electronic (computerized) clinical physiotherapy records. The content of the records and the software’s user acceptability were considered. Methods: A neuro-musculoskeletal patient scenario involving two encounters (initial and follow-up) was scripted and role-played to each of three experienced physiotherapists (A, B and C). Participants assessed the patient and made traditional clinical records. After basic training in an electronic record system, they repeated the assessments and made electronic records via a laptop computer. Three experienced physiotherapists (A, D and E) each used their usual method to write a clinical report and an electronic record …