title: Physical therapists' notes and outcomes of physical therapy. A case of insufficient evidence.
abstract: This article addresses the problem of documenting the outcomes of physical therapy. This is a timely issue because new approaches to reimbursing health-care costs will favor those providers and professions able to demonstrate sufficient benefits to patients to justify prospective cost reimbursement. To assess the adequacy of existing outcome data, we conducted detailed longitudinal audits of 63 geriatric patients' medical records. For nearly half of these patients, the records contained insufficient data to document any improvement in physical functioning. The number of treatments administered correlated with functional improvements documented, but diagnostic related group classifications and patient demographics did not. We found practicing physical therapists overestimated the amount of outcome data recorded and documented some areas of physical functioning more frequently than others. A wider scope for functional assessment and greater standardization in record keeping are advocated. We discuss implications for clinical practice and research and offer a new instrument for quantifying outcomes.
mesh_terms: D000368:Aged; D004282:Documentation; D005260:Female; D006801:Humans; D008297:Male; D008499:Medical Records; D026741:Physical Therapy Modalities