RT Book, Section A1 Shamus, Eric A1 Stern, Debra Feingold SR Print(0) ID 55665001 T1 Chapter 1. Introduction, Background, Purpose, and General Rules for Health Information Management (Medical Record Keeping) T2 Effective Documentation for Physical Therapy Professionals, 2e YR 2011 FD 2011 PB The McGraw-Hill Companies PP New York, NY SN 978-0-07-166404-2 LK accessphysiotherapy.mhmedical.com/content.aspx?aid=55665001 RD 2024/03/28 AB 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.