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INTRODUCTION

OBJECTIVES

Following completion of this chapter, the reader will be able to:

  • Discuss the relationship between health information management and medical record keeping.

  • Identify medical necessity for physical therapy.

  • Define documentation according to the APTA Guide for Physical Therapist Practice.

  • Understand the primary purposes of the medical record.

  • Describe five secondary purposes of the medical record.

  • Explain what is HIPAA and how is it relevant to health information management.

INTRODUCTION, BACKGROUND, AND PURPOSES OF THE RECORD

Clinical documentation is at the core of every patient encounter. In order to be meaningful, it must be accurate, timely, and reflect the scope of services provided. Successful clinical documentation improvement (CDI) programs facilitate the accurate representation of a patient's clinical status that translates into coded data. Coded data is then translated into quality reporting, physician report cards, reimbursement, public health data, and disease tracking and trending.1

Although most purposes of physical therapy documentation have remained constant, in recent years and moving forward, the focus on value-based care is putting increasing emphasis on the need for value-based documentation. The elements of documentation need to imply value orientation.2

Documentation:

  • It is a tool for the planning and provision of physical therapist services and is a communication vehicle among providers.

  • It is a record of care provided, including a report of the individual's status, physical therapist management, and outcome of physical therapist intervention.

  • It may be used to demonstrate compliance with federal, state, payer, and local regulations.

  • It provides a historical account of individual encounters that can be used as evidence in potential legal challenges.

  • It may be used by third-party payers to assess appropriateness of service utilization that is required for payment.

  • It may be used for policy or research purposes, including outcomes analysis.2

As the complexity of healthcare has grown, so has the management of medical or health information, which is “the data related to a person's medical history, including symptoms, diagnoses, procedures and outcomes.”3 HealthIT.gov4 defines an electronic health record (EHR) as a “digital version of a patient's paper chart, that are real time, patient-centered records that make information available instantly and securely to authorized users.” Health information management (HIM) redefines the term medical record keeping as EHR or electronic medical records (EMR) which are now the norm, although some practices may still be using manual entry. The term EMR is a more focused, narrower record of patient health and care, such as that used in physical therapy practice, whereas the EHR is technically more comprehensive. However, the terms are often used interchangeably.

The American Health Information Management Association (AHIMA) is setting the standards for the overall science of HIM in an increasingly complex system.3 A patient chart or record in any form is considered a legal document. As such, it is subject to state and federal ...

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