Evaluation of Physiotherapists’ Documentation: a Retrospective Record Analysis before the Implementation of National Recommendations in the EHR system

Abstract

Objectives: The purpose of this study was to describe and evaluate how physiotherapists have documented patient care in EHR and especially the use of national headings in this documentation and he applicability of classifications in physiotherapy practice in the neurological care setting before the implementation of national recommendations for standardized structure of EHR. Methods: This retrospective study included 1,364 physiotherapists’ notes documented in EHR systems in a central hospital in Finland during the period 2003-2005. This electronic documentation was analyzed using deductive content analysis and statistical methods. Results: Headings were used for the physiotherapy documentation. The use of different headings varied between physiotherapists’ notes and the use of headings was inconsistent. Discussion: Physiotherapists’ documentation has many shortcomings. Physiotherapists’ documentation does not describe whole care process. Use of free text in documentation does not support searching, summarizing, decision support, or statistical analysis. Conclusion: There is a need to use classifications in physiotherapy documentation. The National Classification of Physiotherapy Practice is suitable to document physiotherapists’ interventions and the use of ICF in documentation might provide more detailed information about physiotherapy practice. ICF is more applicable classification in physiotherapy documentation than the National Classification of Physiotherapy Practice.