Introduction, purpose and Introduction, purpose and General Rules for General Rules for DocumentationDocumentation

Dr. Ali Abd El-Monsif ThabetDr. Ali Abd El-Monsif Thabet

Introduction Introduction For physical therapy For physical therapy

professionals, as other professionals, as other health professionals, health professionals, documentation is a required documentation is a required practice by federal, state, practice by federal, state, facility, and accreditation facility, and accreditation laws and guidelineslaws and guidelines

IntroductionIntroduction

Despite its importance, documentation Despite its importance, documentation is often viewed negatively by is often viewed negatively by therapists for at least two reasons. therapists for at least two reasons.

First, and most obvious, too little time First, and most obvious, too little time is given to documentation in the is given to documentation in the clinic.clinic.

Second, therapists are given Second, therapists are given relatively little training in relatively little training in documentation. documentation.

DEFINITION OF DEFINITION OF DOCUMENTATIONDOCUMENTATION

The basic purposes The basic purposes of documentationof documentation

To serve as a basis for To serve as a basis for planning and treatment. planning and treatment.

The basic purposes of The basic purposes of documentationdocumentation

A means of A means of communication for communication for attending health attending health professionals.professionals.

The basic purposes The basic purposes of documentationof documentation

As legal entries describing As legal entries describing the care the patient the care the patient receives.receives.

The basic purposes The basic purposes of documentationof documentation

Verification of services for Verification of services for payers.payers.

The basic purposes The basic purposes of documentationof documentation

As basic data for health As basic data for health research and planning.research and planning.

The basic purposes The basic purposes of documentationof documentation

Quality Assurance Quality Assurance

The basic purposes The basic purposes of documentationof documentation

Hospital decision Hospital decision

Primary and Primary and Secondary PurposesSecondary Purposes

Another division of Another division of purposes of purposes of documentationdocumentation

1.1.Primary : Primary : directly relate to directly relate to patient care.patient care.

2.2.Secondary: Secondary: indirectly indirectly relate to patient carerelate to patient care

The primary The primary purposespurposes

The secondary The secondary purposespurposes

Representative Representative individual users of individual users of healthcare recordshealthcare records

Thank you