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

  • Discuss the need for informed consent and explain the relevance to PT documentation.

  • Define what HIPAA is and the relevance to medical records keeping and PT documentation.

  • Explain what is authentication in documentation.

  • Discuss what are the emerging challenges of protection in electronic or computerized documentation.

  • Explain the importance of legibility in the medical record.

“Effective patient care documentation is as important as the delivery of care itself.”1 The process of health information management by healthcare professionals presents challenges and legal responsibilities. In all documentation, physical therapists (PTs) and physical therapist assistants (PTAs) must abide by professional standards, ethical codes, accreditation standards, the employer's standards, and legal requirements in creating a permanent record of patient data.

PTs are responsible for all aspects of patient care. PTAs work under the direction and supervision of a PT and can:2,3

  • Implement selected components of care and interventions in a competent manner

  • Instruct and counsel patients effectively in exercises

  • Identify a patient's needs and exhibit compassion, caring, and empathy to individual differences

  • Recommend options, courses of action, or modifications in selected treatments, ensuring a patient's progress, safety, and comfort

  • Apply the latest research related to restoring function, reducing symptom frequency, and preventing injury

  • Complete documentation to support the delivery of physical therapy services

  • Perform selected data collection and obtain accurate information

  • Measure performance and report on a patient's medical record

  • Participate in patient status judgments

  • Adhere to ethical and legal standards

  • Ensure continued competence and updated field knowledge

The PT and PTA are responsible for creating, maintaining, and disclosing patient care medical record information as authorized by the patient or as dictated by law. Legally, the records created serve as the best evidence of patient information obtained and shared, the care rendered, the role of the healthcare provider, and whether the professional and legal standards of care were met or breached. For these reasons, PTs and PTAs who document and collect protected health information (PHI) need to understand medical record/health information laws to ensure that they act responsibly and in compliance with applicable laws and identify when expert legal advice is indicated.

The significance of documenting patient care accurately, comprehensively, concisely, objectively, contemporaneously or within a reasonable time, and legibly (although legibility is now best managed by electronic medical records) cannot be overemphasized. The content of the medical record substantiates billing for reimbursement and the need for present and future physical therapy and medical services. The consequences of altered, incomplete, or nonexistent records can be legally and personally catastrophic. Practical application of risk management (prevention of any type of loss—financial or otherwise) and quality care must include proper documentation. The medical record frequently is the most important document available in defending against or preventing legal actions, including but not limited to personal injury suits, criminal cases, ...

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