Medical Record Documentation: The Quality of Physiotherapy Entries

Abstract

This study evaluated the standard of in-patient medical record documentation by physiotherapists at the Royal Adelaide Hospital (RAH), Adelaide, South Australia, during 2003. The impact of patient characteristics (ie primary diagnosis and length of stay in hospital) and physiotherapist features (eg employment classification level and years of employment at the RAH) on the standard of documentation was also explored. One hundred medical records were randomly selected for review and 224 physiotherapy entries were audited. The audit tool was based on the RAH Physiotherapy Department Guidelines for Documentation, which was comprised of five sections. Each section contained several items, which were scored as complete, incomplete, absent or not applicable. The total number of completed scores was calculated for each section of the audit form. A standard of 100 per cent completed was expected for the two sections containing those requirements considered mandatory according to the RAH Physiotherapy Department Guidelines, whereas a lower completion rate was considered acceptable for the remaining sections. The standard of documentation varied considerably, with only five items (4.3%) achieving a rate of 100 per cent completion, namely ‘date’, ‘heading physiotherapy’, ‘signature’, ‘page includes patient details’ and ‘after the first attendance’. In total, 94 items (81.7%) were at least 50 per cent completed, which was considered a reasonable overall standard. The patient diagnosis was the only patient or physiotherapist characteristic that significantly affected the standard of documentation (p = 0.03). While the overall standard of documentation was deemed acceptable, it was clear there was room for improvement.