Fysioterapeuten (Mar 2007)
Fysioterapeuters journaler: en sykehusundersøkelse
Abstract
This article presents major findings of a study in which contributions made by physiotherapists in patient records are subjected to a content analysis. The text material is collected from three wards in a somatic hospital and consists of 67 records. The study documents pronounced differences at the ward level, and the material as a whole demonstrates considerable variation. The text material encompasses records in which physiotherapy is depicted as a function-oriented professional endeavour, but it also includes texts that seem standardised and scanty with a view to functional relationships and clinical assessments. The article provides general overviews as well as detailed analyses of the text material. Most emphasis is given to the part that communicate an individualised approach and which contain descriptions and assessments of qualitative aspects and patterns of the patients' movements and function. It is underscored that the primary function of records is to be a tool for health care providers, and that this must set the stage for other functions (quality assurance, research, lawsuits). Attention is drawn to the importance of writing records to ensure the greatest possible correspondence between practice and written descriptions of it.
