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Physical therapy (PT), although not known by name until modern times, has had a long history. Oral history, recorded information, documents, and archaeological discoveries enable tracing the history of medical practice, including physical medicine, through the ages. While some record keeping was important to previous generations, it is increasingly important for a variety of reasons, although modern standards did not appear until the 20th century. The Hospital Standardization Program established the first requirement for “complete and accurate reporting of the care and treatment provided during hospitalization” in 1918.1 Before 1918, individual physicians haphazardly maintained records according to personal purpose and convenience, unless they were associated with research. With inadequate medical records, it was difficult to ascertain the results of treatment.1 For physical therapists, the implementation of social security and Medicare in 1965 heralded the onset of record keeping or documentation as a component of the medical record.

In some respects, the purposes for documenting have remained constant. However, as the complexity of healthcare has grown, so has the management of medical or health information. Health information management (HIM) is replacing the term medical record keeping. As record keeping transitions increasingly from manual to electronic, the term is more appropriate. The American Health Information Management Association (AHIMA) is setting the standards for the overall science of HIM in an increasingly complex system. The patient chart/record itself is considered a legal document and is, therefore, subject to state and federal laws, as well as medical record laws, HIM laws, state licensure laws for healthcare practitioners, and federal regulation and acts, especially HIPAA (Health Information and Portability Accountability Act). Although HIPAA passed in 1996 it was implemented in 2003. HIPAA set federal standards for accessing and handling medical information.

For physical therapy professionals, as with other health professionals, documentation is a required practice by federal, state, facility, and accreditation laws and guidelines. According to the American Physical Therapy Association (APTA) (Guide to Physical Therapist Practice),2 documentation is “any entry into the medical record” and is required for all patient/client-related encounters. Although required in all settings with some differing requirements, effective, efficient appropriate documentation that complies with all purposes and regulations, and reflects skilled care, can be vexing to the practitioner. Fundamentals are traditionally taught in the academic setting, but the principles learned during one's education need to be practically adapted and applied in the working world. Additionally, as requirements and guidelines are frequently updated by the Centers for Medicare and Medicaid (CMS) for Medicare and Medicaid systems, it is the individual responsibility of each physical therapist or physical therapist assistant, to keep up with changing standards in all settings. As style and required content vary among facilities, organizations, agencies, and therapists, practical application is more challenging than theoretical application.

When the Medicare program was established with Title XVIII of the Social Security Act, physical therapy became a billable service. Under the Act, all practitioners are required ...

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