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

2. 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

3. 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.

4. DEFINITION OF DOCUMENTATION

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

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

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

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

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

10. The basic purposes of documentation Quality Assurance Quality Assurance

11. The basic purposes of documentation Hospital decision Hospital decision

12. 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

13. The primary purposes

14. The secondary purposes

15. Representative individual users of healthcare records

16. Thank you