Introduction, purpose and General Rules for Documentation Dr. Ali Abd El-Monsif Thabet

Introduction For physical therapy professionals, as other health professionals, documentation is a required practice by federal, state, facility, and accreditation laws and guidelines For physical therapy professionals, as other health professionals, documentation is a required practice by federal, state, facility, and accreditation laws and guidelines

Introduction Despite its importance, documentation is often viewed negatively by therapists for at least two reasons. Despite its importance, documentation is often viewed negatively by therapists for at least two reasons. First, and most obvious, too little time is given to documentation in the clinic. First, and most obvious, too little time is given to documentation in the clinic. Second, therapists are given relatively little training in documentation. Second, therapists are given relatively little training in documentation.

DEFINITION OF DOCUMENTATION

The basic purposes of documentation To serve as a basis for planning and treatment. To serve as a basis for planning and treatment.

The basic purposes of documentation A means of communication for attending health professionals. A means of communication for attending health professionals.

The basic purposes of documentation As legal entries describing the care the patient receives. As legal entries describing the care the patient receives.

The basic purposes of documentation Verification of services for payers. Verification of services for payers.

The basic purposes of documentation As basic data for health research and planning. As basic data for health research and planning.

The basic purposes of documentation Quality Assurance Quality Assurance

The basic purposes of documentation Hospital decision Hospital decision

Primary and Secondary Purposes Another division of purposes of documentation Another division of purposes of documentation 1. Primary : directly relate to patient care. 2. Secondary: indirectly relate to patient care

The primary purposes

The secondary purposes

Representative individual users of healthcare records

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