Record Keeping

The purpose of the blog is to provide an informational view on why physical therapists use and maintain record keeping. In addition, this blog will show how physical therapists use record keeping as an aid in rehabilitation.

When an individual hears or thinks of a physical therapist, many often overlook the miscellaneous duties. For example, record keeping is an essential part of being a physical therapist. Medical records, physical records, exercise records are key components in deciding what type of rehab is best for the individual. According to the World Confederation for Physical Therapy (WCPT), recognizing the importance and legal and accurate records is a standard of physical therapy practice and is essential to protection and care of the individuals.2 Records on the individual’s performance yields valuable information. For instance, records show evidence of informed consent, demonstration of client care, facilitate consistent a team approach, and provide a vital source of statistical information for the day-to-day running and future planning of physical therapy.2 There are plenty of more examples, but these hit most of the high points.

Keeping track of the data allows for the physical therapist to apply the progressive overload principle, a muscle or muscle group will increase in strength in direct proportion with the overload placed on it. As a former intern for Dr. Priest’s Lab of Wellness and Motor Behavior (LWMB), I can tell you from personal experience how important, handy, and incidentally convenient having records are for applying that principle. It also allows you to develop a an accurate and personalized program best to achieve individual success. Maintaining and keeping records of individual participation is a tangible evidence that can be shared with a physician, the individual, or other physical therapists to analyze, modify, or review the history.

In conclusion, I have discussed why keeping and maintaining records is an important role of a physical therapist. Also, I have shared a brief description of how record keeping can be used in future rehabilitation. In my final blog, I will discuss the liability involved with physical therapy.

References

1American Physical Therapy Association. (2009, December 14). Guideliines of Physical Therapy Documentation of Patient/Client Management. Retrieved from Documentation Management: https://www.apta.org/uploadedFiles/APTAorg/About_Us/Policies/BOD/Practice/DocumentationPatientClientMgmt.pdf

2World Confederation for Physical Therapy. Policy Statement: Standards of physical therapy practice. London, UK: WCPT; 2011.  (Access date 22nd September 2011)