Chapter 5: Reviewing the Health Record as a Physical Therapist

Introduction

Before a physical therapist first examines a patient, the therapist reviews the patient's health record. This is an essential part of the process of evaluating a patient. The therapist accesses the health record to learn about the patient's medical history, as noted by other healthcare providers, and about the patient's current condition. The therapist then decides about the safety of beginning therapy and notes precautions that must be taken while providing therapy. After reviewing the health record, the therapist examines and evaluates the patient and determines a plan of care.

Sections of the Health Record

Whether in electronic format or paper format, the health record is divided into sections. The name given to a particular section may differ based on facility, but the general information located in each section is similar. The therapist must efficiently and systematically note information from each section that is relevant to the provision of therapy services. When a therapist begins working in a new healthcare facility, it is important to learn the format of the health record, whether electronic or paper. The following sections of the health record are typical sections found in many health records.

Face Sheet

The face sheet contains basic demographic information for the patient. It is usually included in both an inpatient and outpatient health record. The face sheet contains information such as the

• Patient's full name

• Patient's address and phone number

• Health record number (a unique number associated with each patient at that facility)

• Patient's primary and secondary insurance with name and policy numbers (and addresses)

• Name of patient's next of kin/emergency contact, with contact information for that person and her relationship to the patient

Orders

The Orders section is always included in an inpatient health record. It contains all of the orders for the patient, including orders for tests and physical and occupational therapy. An outpatient record for physical therapy often contains a referral form or a prescription for physical therapy, and may or may not be a separate section in an outpatient health record.

In an inpatient setting, it is important to look for recent changes in orders for medications and tests and for updates to orders about the patient's activity level, weight-bearing status, and fluid or food intake. Orders to hold fluids or new orders for medication or tests can indicate a change in the patient's status, which may or may not influence your actions as a therapist.

Physician or Healthcare Provider Notes

In an inpatient setting, an admitting physician's note, known as an H & P (history and physical), contains information about the reason the patient was admitted to the healthcare facility, the patient's medical history, and information about the patient's current condition as described by the patient's physician. ...