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Documenting Physical Therapy
Book reviews
161
Documenting Physical Therapy The reviewer perspective Butterworth-Heinemann, Oxford 1999 (ISBN 0 7506 9950 7). 249 pages by Angela M Baeten, Michael L Moran and Lynn M Phillippi £30 The motivation for writing this book is not explicitly stated but can be deduced from the second sentence of the preface, which reads: ‘As the healthcare dollar continues to shrink, the physical therapist's ability to obtain payment for services is contingent on functional documentation that describes the need for skilled care.’ This suggests that American physiotherapists experience difficulty in obtaining payment for the treatments they have administered because their patient notes are not good enough to support their claims without question, and that the motivation for writing the book is to provide a means for relieving this difficulty as much as possible. The aim in writing the book is also not explicitly stated but can be deduced from the second sentence of the fourth paragraph of the preface, which reads: ‘It is our intention to provide the reader with the skills to analyse documentation from a reviewer's perspective.’ This suggests that the aim of the book is to show American physiotherapists how to record the treatments they have administered, to reduce as much as possible the need felt by purchasers to raise questions about the validity of claims for payment. In the United Kingdom patient notes tend to be regarded as serving the single purpose of a legal document, and it would be reasonable to regard the book as having little relevance to UK physiotherapists. However, to do so would be a mistake. In this country, when the treatment received by a patient comes under legal scrutiny, confirming the clinical content of the notes made by the physiotherapist for the patient becomes a priority. The questions that are asked by UK lawyers then are the same as those asked by American purchasers of physiotherapy services to establish the validity of claims for payment. When the treatment received by a patient comes under legal scrutiny, the patient notes provide the lawyers with their first contact with the therapist. This contact is of crucial importance as it creates an impression of the clinical competence of the therapist. This impression is informed by the content of the patient notes. If they are ambiguous they give the impression of a lack of clinical competence in administering treatment; unambiguous notes do the opposite. These impressions occur even though there is no necessary cause-effect relationship between the clarity of the notes and competence in administering treatment. Notes written in a standard format have the appearance of clarity,
and suggest that the treatment was administered with clinical competence. This has the advantage of reducing the scope for raising critical questions about the administration of the treatment, and casting unwarranted doubts on the clinical competence of the therapist who administered the treatment. The book proposes a standard format, and gives examples of patient notes in that format. In writing patient notes, physiotherapists usually are not aware that they are using ordinary, everyday language out of context and creating a problem. The problem arises because they are using that language for a purpose for which it was not developed, namely, to convey clinical information. The difficulty is that the notes do not adequately convey the nature and extent of the treatment received by a patient, or of the effect of that treatment. The problem is reduced by redefining ordinary, everyday words such as ‘better’, ‘same’, ‘worse’, ‘increased’ and ‘decreased’, to give them clinical meanings. The effect of such redefinition is that it minimises the scope for raising critical questions about the administration of the treatment, and casting possibly unwarranted doubts on the clinical competence of the therapist who administered the treatment. The book gives examples of patient notes which contain commonly used words which should be redefined to have a clinical meaning, but does not explain how this should be done routinely. However, providing the explanation was not its purpose. TELER (le Roux, 1993, 2001) users know how to redefine commonly used words for clinical use. This is illustrated by the work of a group of nurses (Grocott et al, 2001). The writing style is somewhat stilted and off-putting, making the book rather more difficult to read than might have been expected. It is nevertheless an indispensable aid to any physiotherapist interested in writing patient notes that accurately describe the treatment administered and its effects, and it should be required reading for all physiotherapy students before they go on placement. The book should also be a standard reference work in every physiotherapy department. Bunny le Roux MSc References Grocott, P, Richardson, A, Kearney, N, Ambaum, B and Redmond, K (200l). ‘Nursing in colorectal cancer initiative: The audit phase: Part 1, Development of the audit tool’, European Journal of Oncology Nursing, submitted for publication. le Roux, A A (1993). ‘TELER™: The Concept’, Physiotherapy, 79, 11, 755-758. le Roux, A A (2000). TELER Information Pack, TELER, Sheffield, 7th edn.
Physiotherapy March 2001/vol 87/no 3
161
Documenting Physical Therapy The reviewer perspective Butterworth-Heinemann, Oxford 1999 (ISBN 0 7506 9950 7). 249 pages by Angela M Baeten, Michael L Moran and Lynn M Phillippi £30 The motivation for writing this book is not explicitly stated but can be deduced from the second sentence of the preface, which reads: ‘As the healthcare dollar continues to shrink, the physical therapist's ability to obtain payment for services is contingent on functional documentation that describes the need for skilled care.’ This suggests that American physiotherapists experience difficulty in obtaining payment for the treatments they have administered because their patient notes are not good enough to support their claims without question, and that the motivation for writing the book is to provide a means for relieving this difficulty as much as possible. The aim in writing the book is also not explicitly stated but can be deduced from the second sentence of the fourth paragraph of the preface, which reads: ‘It is our intention to provide the reader with the skills to analyse documentation from a reviewer's perspective.’ This suggests that the aim of the book is to show American physiotherapists how to record the treatments they have administered, to reduce as much as possible the need felt by purchasers to raise questions about the validity of claims for payment. In the United Kingdom patient notes tend to be regarded as serving the single purpose of a legal document, and it would be reasonable to regard the book as having little relevance to UK physiotherapists. However, to do so would be a mistake. In this country, when the treatment received by a patient comes under legal scrutiny, confirming the clinical content of the notes made by the physiotherapist for the patient becomes a priority. The questions that are asked by UK lawyers then are the same as those asked by American purchasers of physiotherapy services to establish the validity of claims for payment. When the treatment received by a patient comes under legal scrutiny, the patient notes provide the lawyers with their first contact with the therapist. This contact is of crucial importance as it creates an impression of the clinical competence of the therapist. This impression is informed by the content of the patient notes. If they are ambiguous they give the impression of a lack of clinical competence in administering treatment; unambiguous notes do the opposite. These impressions occur even though there is no necessary cause-effect relationship between the clarity of the notes and competence in administering treatment. Notes written in a standard format have the appearance of clarity,
and suggest that the treatment was administered with clinical competence. This has the advantage of reducing the scope for raising critical questions about the administration of the treatment, and casting unwarranted doubts on the clinical competence of the therapist who administered the treatment. The book proposes a standard format, and gives examples of patient notes in that format. In writing patient notes, physiotherapists usually are not aware that they are using ordinary, everyday language out of context and creating a problem. The problem arises because they are using that language for a purpose for which it was not developed, namely, to convey clinical information. The difficulty is that the notes do not adequately convey the nature and extent of the treatment received by a patient, or of the effect of that treatment. The problem is reduced by redefining ordinary, everyday words such as ‘better’, ‘same’, ‘worse’, ‘increased’ and ‘decreased’, to give them clinical meanings. The effect of such redefinition is that it minimises the scope for raising critical questions about the administration of the treatment, and casting possibly unwarranted doubts on the clinical competence of the therapist who administered the treatment. The book gives examples of patient notes which contain commonly used words which should be redefined to have a clinical meaning, but does not explain how this should be done routinely. However, providing the explanation was not its purpose. TELER (le Roux, 1993, 2001) users know how to redefine commonly used words for clinical use. This is illustrated by the work of a group of nurses (Grocott et al, 2001). The writing style is somewhat stilted and off-putting, making the book rather more difficult to read than might have been expected. It is nevertheless an indispensable aid to any physiotherapist interested in writing patient notes that accurately describe the treatment administered and its effects, and it should be required reading for all physiotherapy students before they go on placement. The book should also be a standard reference work in every physiotherapy department. Bunny le Roux MSc References Grocott, P, Richardson, A, Kearney, N, Ambaum, B and Redmond, K (200l). ‘Nursing in colorectal cancer initiative: The audit phase: Part 1, Development of the audit tool’, European Journal of Oncology Nursing, submitted for publication. le Roux, A A (1993). ‘TELER™: The Concept’, Physiotherapy, 79, 11, 755-758. le Roux, A A (2000). TELER Information Pack, TELER, Sheffield, 7th edn.
Physiotherapy March 2001/vol 87/no 3