|ORIGINAL RESEARCH REPORT
|Year : 2015 | Volume
| Issue : 2 | Page : 85-89
Analysis of physiotherapy documentation of patients' records and discharge plans in a tertiary hospital
Olajide A Olawale1, Ashiyat K Akodu1, Emilia A Tabeson2
1 Department of Physiotherapy, College of Medicine, University of Lagos, Lagos, Nigeria
2 Department of Physiotherapy, State House Medical Centre, Abuja, Nigeria
|Date of Web Publication||17-Nov-2015|
Olajide A Olawale
Department of Physiotherapy, Faculty of Clinical Sciences, College of Medicine, University of Lagos, PMB 12003, Lagos
Source of Support: None, Conflict of Interest: None
Background and Objective: Accurate documentation promotes continuity of care and facilitates dissemination of information concerning the patient to all members of the health care team. This study was designed to analyze the pattern of physiotherapy documentation of the patients' records and discharge plans in a tertiary hospital in Lagos, Nigeria. Materials and Methods: A total of 503 case files from the four units of the Physiotherapy Department of the hospital were examined for accuracy of records. The D-Catch instrument was used to quantify the accuracy of record structure, admission data, physiotherapy examination, physiotherapy diagnosis, patients' prognoses based on the plan of care, physiotherapy intervention, progress and outcome evaluation, legibility, and discharge/discontinuation plan. Results: “Accuracy of legibility” domain had the highest accuracy score: 401 (79.72%) case files had an accuracy score of 4. The domain “accuracy of the discharge/discontinuation summary” had the lowest accuracy score: 502 (99.80%) case files had an accuracy score of 1. Conclusion: Documentation of the plan of care made in the hospital for the period of this study did not fully conform to the guidelines of the World Confederation for Physical Therapy (WCPT). The accuracy of physiotherapy documentation needs to be improved in order to promote optimal continuity of care, improve efficiency and quality of care, and recognize patients' needs. Implementation and use of electronically produced documentation might help physiotherapists to organize their notes more accurately.
Keywords: Analysis, discharge plan, patients' records, physiotherapy, physiotherapy documentation
|How to cite this article:|
Olawale OA, Akodu AK, Tabeson EA. Analysis of physiotherapy documentation of patients' records and discharge plans in a tertiary hospital. J Clin Sci 2015;12:85-9
|How to cite this URL:|
Olawale OA, Akodu AK, Tabeson EA. Analysis of physiotherapy documentation of patients' records and discharge plans in a tertiary hospital. J Clin Sci [serial online] 2015 [cited 2019 Mar 26];12:85-9. Available from: http://www.jcsjournal.org/text.asp?2015/12/2/85/169687
| Introduction|| |
Physiotherapy is a dynamic profession with an established theoretical base, and widespread clinical application in the development and restoration of optimal function. The “complexity and breadth” of the physiotherapy profession has grown beyond the scope of general practice. Continuing professional development is now essential to ensure service quality and has become a professional responsibility. Physiotherapy is a profession that forms an active part of the health care team in the management of patients with various conditions using the patient-centered care approach.
Physiotherapy documentation is an important legal and professional requirement., Accurate documentation facilitates information concerning the patient to all members of the health care team, which is vital to ensure holistic patient care. In addition, physiotherapy documentation can be used for research and quality activities and for medicolegal purposes.,,
The World Confederation for Physical Therapy (WCPT) recommends that accurate physiotherapy documentation should include personal data, consent, examination, evaluation, diagnosis, prognosis, plan of care, interventions/treatment, reexamination, and the results. Outcomes and recording of the achievement of goals and expected outcomes, including patients' expectations and recording of any adverse reactions related to the treatment given and any action taken by the physiotherapist must also be documented. Physiotherapy documentation should also include information on any referral received and referral made to other sources/personnel, home program, education and equipment provided, date of any cancelled or missed appointments and reasons where relevant, discharge plan, date of discharge or discontinuation of physiotherapy, and discharge or discontinuation summary.
The ability to document patients' responses to treatment and information about the care given is a core competence of physiotherapists., It has also been asserted that the greatest conceptual issue impeding better physiotherapy treatment outcomes in patients' conditions is the failure to make accurate documentation, which leads to adverse outcomes that are often not documented. The frequency of documenting progress notes will depend on the individual patient, the type of care provided, and the requirement to accurately record the events of the episode of care.
Although there is no internationally accepted gold standard for measuring the accuracy of physiotherapy documentation, there are internationally accepted processes with theoretical elements in making accurate physiotherapy documentation. Accurate physiotherapy documentation allows physiotherapists to evaluate physiotherapy outcomes as a logical result of physiotherapy diagnoses and interventions., Striving for consensus on the role of diagnosis in patient management should become a priority as well as developing a more standard taxonomy with consistent terminology. The documentation needs to be coherent, relevant, unambiguous, and linguistically correct. Hence, this study was carried out to investigate the pattern of accurate physiotherapy documentation of patients' records and discharge plans in a tertiary hospital in Lagos, Nigeria.
| Materials and Methods|| |
Patients' case files from the four units of the physiotherapy department of a tertiary hospital located in Lagos, Nigeria were examined. The four units were pediatrics, surgery/obstetrics and gynecology, medicine/neurology, and orthopedics. The case files were obtained from the records office of the department. All the case files documented in the four units of the department for the 2 years of the study (2009 and 2010) were included if they met the following two inclusion criteria: (1) The patient's length of stay was of at least 3 days and (2) the patient was no longer receiving physiotherapy treatment in the hospital. The D Catch instrument was used to quantify the accuracy of record structure (according to the physiotherapy process), admission data (information from the admission interview), physiotherapy examination (subjective and objective assessment), physiotherapy diagnosis (potential intervention based on the diagnosis), patient's prognoses based on the plan of care, physiotherapy intervention, progress and outcome evaluation, legibility (readable handwriting or typewritten), and discharge/discontinuation plan.
The research instrument (D-Catch instrument) was adapted from an earlier study on the prevalence of accurate physiotherapy documentation in patients' records. It consists of a chronological descriptive accuracy construct (8 items) and a diagnostic accuracy construct (1-item). Items 2-8 were measured as a sum score of questions on quantity and quality criteria; items 1 and 9 were measured as a sum score of questions on quality alone. Quantity criteria addressed the question: “Are the components of the document present?” Quality criteria addressed the question: “What is the quality of the description with respect to relevancy, unambiguity, and linguistic correctness?” Quantity criteria were scored as follows: Complete = 4 points, partially complete = 3 points, incomplete = 2 points, and none = 1 point. Quality criteria were scored as follows: Very good = 4 points, good = 3 points, moderate = 2 points, and poor = 1 point.
Ethical approval was obtained from the Health Research and Ethics Committee of the hospital (REF: ADM/DCST/HREC/VOL.XV/348).
Procedure for data collxection
The study involved all patient case files documented for the 2 years of the study (2009 and 2010). All the 1,500 case files documented in the four units of the department for the 2 years were examined. A total of 503 case files met the inclusion criteria. Each of the case files was assessed by three assessors, namely, the main assessor and two independent assessors who had been previously trained on how to score items on the D-Catch instrument.
The data were analyzed using Statistical Package for Social Sciences (SPSS) version 17.0 (SPSS Inc., Chicago, IL, USA). The data were summarized using frequencies and percentage scores. The inter-rater reliability of the D-Catch instrument was tested using Cohen's weighted kappa (κ). The scores were aggregated and transformed according to a 100-point scale.
| Results|| |
Case files examined
A total of 503 medical case files were examined. They comprised 361 (72%) files for 2009 and 142 (28%) files for 2010. They contained records for 172 patients in the pediatrics unit, 242 patients in the orthopedics unit, 47 patients in the surgery/obstetrics and gynecology unit, and 42 patients in the medicine/neurology unit.
Pattern of physiotherapy record structure
Many case files maintained a complete pattern of physiotherapy record structures with an accuracy score of 4 for the 2 years. A total of 237 (47.12%) case files contained all of the physiotherapy process phases while 20 (3.98%) were not structured at all according to these phases.
Accuracy in the pattern of documentation
Of the 503 case files examined, the highest accuracy score was found on legibility: 401 (79.72%) case files had an accuracy score of 4 [Table 1]. The lowest score was found on the accuracy of documentation of the discharge/discontinuation summary: 502 (99.80%) case files had an accuracy score of 1 [Table 2]. The complete personal details of the patients were present in 109 (21.67%) case files while 113 (22.47%) revealed complete admission information, contained medical diagnoses, and reasons for admission. In most (401, 79.7%) of the case files, the notes were clear and contained relevant information.
|Table 1: Description of accuracy in the pattern of documentation (quantity)|
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|Table 2: description of accuracy in the pattern of documentation (quality)|
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There were 21 case files (4.17%) that contained no subjective examination and 153 (30.42%) case files had an accuracy score of 4 [Table 1]. There were 29 case files (5.77%) that had no objective examination and 107 (21.27%) contained full documentation of the systems and tests/measurements [Table 1]. A total of 248 (49.30%) case files revealed that the diagnoses implied the possibility of an intervention while 170 (33.80%) contained no diagnosis. There were 172 (34.19%) case files that mentioned diagnosis labels, which were not supported by any note and were linguistically incorrect [Table 2]. Only three (0.60%) case files documented the plan of care with an accuracy score of 4 and only three (0.60%) had plans of care that led to an accurate intervention [Table 1]. There were 348 (69.18%) case files, which showed that each intervention in terms of physiotherapy actions can be directly related to a diagnosis. There were 26 (5.17%) case files that had no intervention mentioned [Table 1].
Only 43 (8.55%) case files revealed that their progress evaluations were linked to diagnoses and interventions, and they appeared to logically result from the diagnosis [Table 1]. There were 401 (79.72%) case files that were legibly written with a mean score of 4 and 502 (99.80%) had no discharge/discontinuation summary [Table 2].
| Discussion|| |
In this study, patients' case files were examined with the aim of describing the accuracy of documentation of patients' records. The domain “accuracy of legibility” had the highest accuracy score while the domain “accuracy of the discharge/discontinuation summary” had the lowest accuracy score. Other domains recorded different levels of accuracy in their documentation. One notable limitation of this study was the relatively small number of case files assessed for the accuracy of documentation. Perhaps, more robust and comparable results would have been obtained with a larger number of patients' case files and if the study had utilized a multicenter design.
Analysis of the accuracy of the record structure showed that 237 (47.12%) case files were completely structured according to the physiotherapy process phases. This means that only these number of case files conformed to the nine-step process developed by the American Physical Therapy Association. Also, 109 (21.67%) case files documented complete personal details of the patients that focused on the format of the admission reports and how linguistically correct they were. There was no association between the accuracy of physiotherapy report about the admission of patients and physiotherapy diagnoses, interventions, and progress and outcome evaluations. This is evident by the number of case files that had accuracy score of 4; 109 case files for the physiotherapy report, 248 case files for diagnoses, 348 case files for interventions, and 43 case files for progress and outcome evaluation. In a particular study, it was reported that there was a relationship between the accuracy of reported admission information, physiotherapy diagnoses, interventions, and progress and outcome evaluations. This type of relationship could not be established with the results of this study.
The outcome of this study revealed that only 153 case files contained subjective examination with accuracy score of 4, and 107 case files contained objective examination and 248 case files contained physiotherapy diagnoses, both with accuracy score of 4. This implies that poor diagnosis is a result of poor examination. Incomplete documentation was found in 350 case files for subjective examination, 351 case files for objective examination, and 171 case files for physiotherapy diagnoses. This shows the presence of inaccurate documentation of the physiotherapy process phases. This finding is similar to that reported in one study where it was confirmed that inaccurate physiotherapy documentation emanates from poor diagnosis that results from poor examination. Also, it should be noted that poor examination limits the ability of a physiotherapist to generate an accurate prognosis for the formulation of a very good plan of care that is essential for patient management.
Out of the 503 case files examined, 248 (49.30%) contained complete documentation of the physiotherapy diagnoses. Hence, only few accurately formulated diagnoses that were presented according to the PE (P = problem, E = etiology) structure were documented. It was stated in a study that the PE structure had been shown to be the way of documenting diagnostic findings. Results of the present study are similar to those reported in some other studies,, where it was indicated that patients' records contained relatively few accurately formulated diagnoses, related factors, and pertinent signs and symptoms. The outcome of this study also indicated that 170 case files had no diagnoses documentation made while some revealed a lack of relationship between the diagnosis and planned intervention. This finding concurs with the report of another study where it was reported that inaccurate documentation results from lack of relationship between diagnosis and treatment decisions.
The findings of this study revealed that only three case files contained a plan of care with accuracy score of 4. This implies that documentation of the plan of care made in the hospital for the period of this study did not conform to WCPT guidelines for the plan of care documentation. When there is poor documentation of the plan of care, anticipated discharge plan is impossible. This is evident in this study as no case file contained a discharge plan with an accuracy score of 4. In an earlier study, it was concluded that plan of care should include the anticipated discharge plans in consultation with appropriate individuals.
The results of this study also revealed that 43 case files contained progress evaluations that were linked to diagnoses and interventions and appeared to logically result from the diagnosis. This implies that the details of the progress and outcome evaluations were poorly documented. This observation is similar to that of another study where it was reported that the details of treatment outcomes were poorly documented. The finding that 131 case files had neither any progress evaluation nor any outcome evaluations mentioned correlates with the findings of other studies where it was concluded that clinicians in the rehabilitation field do not regularly use outcomes measures.,
In this study, it was also found out that 401 case files were legibly documented. Also, no case file contained a discharge plan with an accuracy score of 4. This implies that no discharge plans are made and this could be as a result of poor documentation of the plan of care, as earlier stated. Hence, it was not possible to integrate patients' present condition in making accurate discharge plans. This is not in line with the findings of a study where it was stated that physiotherapists are able to integrate multiple patient factors to make accurate and appropriate discharge recommendations.
| Conclusion|| |
Findings from the study suggest that physiotherapy documentation accuracy needs to be improved in order to promote optimal continuity of care, improve efficiency and quality of care, and recognize patients' needs and adverse events. Due to poor documentation, it was not possible to establish a relationship between the accuracy of physiotherapy report about the admission of patients and physiotherapy diagnoses, interventions, and progress and outcome evaluations.
Implementation and use of the electronically produced documentation might help physiotherapists to organize their notes more accurately. Additional studies are required to know in more depth whether supplementary factors affecting the accuracy of physiotherapy documentation influenced our findings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Physical Therapy Association. Guidelines for Physical Therapy Documentation. Available from: http://www.apta.org
. [Last accessed on 2013 Jun 30].
Chartered Society of Physiotherapy. General Principles of Records Keeping and Access to Health Records. PA47. Availabe from: http://www.csp.org
. [Last accessed on 2013 Jun 30].
Gumery L, Sheldon H, Bayliss H, Mackle R, Stableforth D, Honeybourne D, et al
. Do physiotherapy records meet international standard? Physiotherapy 2001;86:655-9.
Phillips A, Stiller K, Williams M. Medical record documentation: The quality of physiotherapy entries. The Int J Allied Hlth Sci and Practice 2006;1:1540-80.
Richoz C, Ayer A, Berchtold A, Richoz S. Record keeping by Swiss physiotherapists. Euro J of Med Sci 2008;10:4414.
Tobin A, Judd M. Understanding the barriers. Physiotherapy 1998;84:527-9.
Olaitan PB, Oseni GO. Clinical photography among African cleft caregivers. Indian J Plast Surg 2011;44:484-7.
World Confederation for Physical Therapy. Draft Position Statement - Appendix to Physical Therapy Record Keeping, Storage and Retrieval. Available from: http://www.wcpt.org
. [Last accessed on 2013 Jun 20].
Ginsbury L, Tregunno D. Perceptions of patient safety culture by different stakeholder groups. J Acad Med 2005;80:955-63.
Walsh C. Patient records improve with unified case notes. Nurs Times 1998;94:52-3.
Scholey ME. Documentation: A means of professional development. Physiotherapy 1985;71:276-8.
Arseneault L, Cannon M, Witton J, Murray RM. Causal association between cannabis and psychosis: Examination of the evidence. Br J Psychiatry 2004;184:110-7.
Spoto MM, Collins J. Physiotherapy diagnosis in clinical practice: A survey of orthopaedic certified specialists in the USA. Physiother Res Int 2008;13:31-41.
Paans W, Sermeus W, Nieweg RM, van der Schans CP. Prevalence of accurate nursing documentation in patient records. J Adv Nurs 2010;66:2481-9.
Moran MT, Wiser TH, Nanda J, Gross H. Measuring medical residents' chart-documentation practices. J Med Educ 1988;63:859-65.
Fary RE, Briffa NK, Briffa TG. Effectiveness of pulsed electrical stimulation in the management of osteoarthritis of the knee: Three case reports. Physiother Theory Pract 2009;25:21-9.
Kamkar A. Therapeutics exercises. J Orthop Sports Phys Ther 2000;30:390-2.
M'kumbuzi VR, Eales VJ, Stewart A. An analysis of the completion of physiotherapy clinical records in Gauteng Province. S Afr J Physiother 2002;58:18-27.
Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely Ill. Phys Ther 2010;90:693-703.
Deathe B, Miller WC, Speechley M. The status of outcome measurement in amputee rehabilitation in Canada. Arch Phys Med Rehabil 2002;83:912-8.
Skinner A, Turner-Stokes L. The use of standardized outcome measures in rehabilitation centers in the UK. Clin Rehabil 2006;20:609-15.
[Table 1], [Table 2]