Dokumentation: das Spiegelbild professioneller Therapie

Patrick Heldmann

doi:10.1055/a-1869-5432

MSK – Muskuloskelettale Physiotherapie, Table of Contents

MSK – Muskuloskelettale Physiotherapie 2022; 26(04): 189-195
DOI: 10.1055/a-1869-5432

Schwerpunkt

Vertiefung

Dokumentation: das Spiegelbild professioneller Therapie

Authors

Patrick Heldmann

Abstract

Ein Blick in die Leitlinien internationaler Verbände oder Organisationen der Physiotherapie gibt Impulse, wie die Dokumentation gestaltet werden könnte. Anhand von Leitfragen werden die einzelnen Empfehlungen und Kriterien vorgestellt – für eine bessere Orientierung im Dokumentationsdschungel.

Full Text

References

Literatur
1 Bundesministerium der Justiz. Bürgerliches Gesetzbuch (BGB). § 630f Dokumentation der Behandlung. Im Internet: Accessed June 11, 2022 at: https://www.gesetze-im-internet.de/bgb/__630f.html
2 Bundesrahmenvertrag (01.08.2021). Anlage 1. Leistungsbeschreibung zum Vertrag nach § 125 Absatz 1 SGB V über die Versorgung mit Leistungen der Physiotherapie und deren Vergütung. Im Internet: Accessed June 15, 2022 at: https://bit.ly/3Qr9e6L
3 Australian Physiotherapy Association (APA). Guidelines for writing clinical notes. APA 2018. Im Internet: Accessed June 17, 2022 at: https://australian.physio/tools
4 Chartered Society Of Physiotherapy (CSP). Record Keeping Guidance (12.01.2021). Im Internet: Accessed February 08, 2022 at: https://www.csp.org.uk/system/files/publication_files/RecordKeepingFINAL_Sara%20Conroy.pdf
5 Canadian Alliance Of Physiotherapy Regulators (CAPR). Core standards of practice for Physiotherapists in Canada (31.01.2018). Im Internet: Accessed February 08, 2022 at: https://www.alliancept.org/announcement/core-standards-practice-physiotherapists-canada-now-available/
6 Physiotherapy Board of New Zealand (PBNZ). Physiotherapy health records standard (05.2018). Im Internet: Accessed February 08, 2022 at: https://www.physioboard.org.nz/standards/physiotherapy-standards/physiotherapy-health-records-standard
7 World Physiotherapy. Guideline: Physical therapy records management: record keeping, storage, retrieval and disposal (06.2011). Im Internet: Accessed February 08, 2022 at: https://world.physio/guideline/records-management
8 O’Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 7th ed.. Philadelphia: F. A. Davis; 2019
9 Heldmann P, Werner C, Belala N. et al. Early inpatient rehabilitation for acutely hospitalized older patients: a systematic review of outcome measures. BMC Geriatr 2019; 19: 189
10 Kyte DG, Calvert M, van der Wees PJ. et al. An introduction to patient-reported outcome measures (PROMs) in physiotherapy. Physiotherapy 2015; 101: 119-125
11 Greiner W, Claes C, Busschbach JJV. et al. Validating the EQ-5D with time trade off for the German population. Eur J Health Econ 2005; 6: 124-130
12 Fairbank JC, Couper J, Davies JB. et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy 1980; 66: 271-273
13 Heldmann P, Schöttker-Königer T, Schäfer A. Cross-cultural Adaption and Validity of the „Patient Specific Functional Scale”. International Journal of Health Professions 2015; 2: 73-82
14 Huhn K, Gilliland SJ, Black LL. et al. Clinical Reasoning in Physical Therapy: A Concept Analysis. Phys Ther 2019; 99: 440-456
15 Griefahn A, Wolf E, Zalpour C. Wie kann die Dokumentation in der Physiotherapie durch die Digitalisierung effektiver und effizienter werden?. physioscience 2020; 16: 101-110
16 Sando KR, Skoy E, Bradley C. et al. Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Curr Pharm Reach Learn 2017; 9: 576-584
17 Santiago LM, Neto I. SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context. Acta Med Port 2016; 29: 854-859
18 Steiner WA, Ryser L, Huber E. et al. Use of the ICF Model as a Clinical Problem-Solving Tool in Physical Therapy and Rehabilitation Medicine. Phys Ther 2002; 82: 1098-1107
19 World Health Organization. International Classification of Functioning, Disability and Health. In World Health Organization (Hrsg.). Geneva: World Health Organization; 2001 Im Internet: Accessed June 17, 2022 at: https://bit.ly/3mY224I
20 Hill JC, Dunn KM, Lewsi M. et al. A primary care back pain screening tool: identifying patient subgroups for initial treatment. Arthritis Rheum 2008; 59 (05) 632-41
21 verywellhealth. Physical Therapy Abbreviations Commonly Used by PTs (24.01.2022). Im Internet: Accessed February 09, 2022 at: https://www.verywellhealth.com/physical-therapy-abbreviations-2696107