Analysis of physiotherapy documentation of patients′ records and discharge plans in a tertiary hospital

Abstract

Background and Objective: Accurate documentation promotes continuity of care and facilitates dissemination of information concerning the patient to all members of the health care team. This study was designed to analyze the pattern of physiotherapy documentation of the patients' records and discharge plans in a tertiary hospital in Lagos, Nigeria. Materials and Methods: A total of 503 case files from the four units of the Physiotherapy Department of the hospital were examined for accuracy of records. The D-Catch instrument was used to quantify the accuracy of record structure, admission data, physiotherapy examination, physiotherapy diagnosis, patients' prognoses based on the plan of care, physiotherapy intervention, progress and outcome evaluation, legibility, and discharge/discontinuation plan. Results: “Accuracy of legibility” domain had the highest accuracy score: 401 (79.72%) case files had an accuracy score of 4. The domain “accuracy of the discharge/discontinuation summary” had the lowest accuracy score: 502 (99.80%) case files had an accuracy score of 1. Conclusion: Documentation of the plan of care made in the hospital for the period of this study did not fully conform to the guidelines of the World Confederation for Physical Therapy (WCPT). The accuracy of physiotherapy documentation needs to be improved in order to promote optimal continuity of care, improve efficiency and quality of care, and recognize patients' needs. Implementation and use of electronically produced documentation might help physiotherapists to organize their notes more accurately.

Keywords

• Analysis
• discharge plan
• patients' records
• physiotherapy
• physiotherapy documentation