Retrospective chart review
Appreciate the need to document objective data in clinical practice systematically.
Contrast the steps of patient care management with outcome research processes.
Describe the challenges of using clinical documentation as a source for retrospective case studies and cohort data.
“Am I an effective clinician?”
“How many of my patients achieve their goals?”
“Are my patients satisfied with their gains?”
“Can my treatments be more efficient or effective?”
These are the questions that drive a reflective practitioner. There are many definitions of “effective,” and there are many strategies for reviewing a clinician’s individual decision-making processes. This textbook will guide the physical therapist (PT) through one method of evaluating clinical practice by using daily documentation as a source for retrospective data. By looking backward, a clinician will be able to compare intuitive perceptions of process or effectiveness with objective measures of service delivery.
Every clinician can learn to translate routine patient documentation into data sets in order to measure personal service outcomes. Health service delivery has entered the era of evidence-based practice. Patients, peers, and regulatory agencies are holding health-care providers to a higher level of accountability than ever before. They want measurable evidence that an intervention is yielding positive results for the least amount of money. Consumers and payers want their money’s worth, and satisfaction is linked to the achievement of expected results (Keith, 1998; Kramer, 1997; McKinley, et al., 2002). Although the literature supporting physical therapy interventions and outcomes is growing steadily, there is still a dearth of rigorous clinical trials and clinically applicable outcomes that provide clinicians with the published support for many intervention strategies (Delitto, 2005; Duckworth, 1999; Jette, 2005). So, on the one hand, patients, payers, and clinicians want evidence of effectiveness. On the other hand, the literature does not provide the breadth and depth of support for the many problems and approaches that PTs address. What is a clinician to do?
A Challenge: Consumers and clinicians want evidence of effectiveness, but there is limited support for many intervention strategies.
One solution to this dilemma is to view each patient as a case study. The patient becomes a sample of n=1 and presents a unique opportunity to test a clinical hypothesis about the best strategy to achieve that patient’s goals. Daily documentation on initial patient status and subsequent changes during the course of patient management become the data set. When the measurements on a desired change demonstrate improvement, they support the choice of interventions for this particular patient at this particular time. When the measurements decline or do not change as expected, that evidence supports a change in intervention strategy. Use of patient data for clinical decision making is part of the classical triad of evidence-based ...