Chapter 6: Writing in a Health Record

Introduction

Because therapists and therapist assistants write in patient health records, it is important to understand the rationale behind documenting patient care. Therapists and assistants must also develop the special writing habits and skills needed for writing in a health record.

The Purposes of Documentation in Physical Therapy

Physical therapists and physical therapist assistants document their findings for several reasons, including the following:

Legal Considerations

Patient care notes record what the therapist does to manage the patient's case. These notes are placed in the patient's health record. This documentation is an integral aspect of the care that every patient receives.¹ Patient care notes ensure that the rights of the therapist and the patient are protected legally should any question arise regarding the care provided to the patient. Patient care notes are considered legal documents, as are all parts of the health record, for 7 years from the time treatment is terminated. In the event of litigation, the health record may be subpoenaed, and the therapist may be called to testify in court or in a deposition on the contents of the health record. The information in the patient care notes is recorded at the time of care and may be more accurate than the therapist's memory,² especially if several years pass between the time the therapist treats the patient and the litigation.

Communication

According to the Guide to Physical Therapist Practice, part of the role of the physical therapist is communication.¹ Good documentation is a method of communicating with all other healthcare professionals, including other therapists, therapy assistants, and referring medical practitioners.^3,4 The patient care note communicates the results of the examination, the therapist's evaluation, the diagnosis, and the patient's prognosis. It communicates the therapist's and patient's expected outcomes and anticipated goals for the patient as well as the intervention plan, also known as the plan of care. The goal of such communication is to provide consistency and coordination among the services provided by various healthcare professionals.¹

A good patient care note can be a helpful tool for communication with other therapists within the same discipline who may provide substitute care for patients during the primary therapist's absence or as part of team approach to treatment between a group of physical therapists and physical therapy assistants. In a rehabilitation center, school, hospital, or other setting that uses an interprofessional rehabilitation team approach, the therapist's goals and the patient's level of function can be communicated to other professionals involved in the patient's care. Professionals providing services after the patient is discharged from one therapist's care may find the therapist's notes to be valuable in planning appropriate follow-up care.¹

Reimbursement

Third-party payors, such as Medicare reviewers and representatives from insurance companies, ...