Disablement Models

and the ICF

Framework
Learning Objectives
1. Define a functional outcome, and discuss its importance in physical
therapy documentation.
2. Explain the concept of disablement and its relevance to physical
therapist practice.
3. Define the components of the International Classification of
Functioning, Disability and Health (ICF)model.
4. Classify clinical observations and measurements according to the
ICF.
Functional Outcome
• Documentation should focus on functional outcomes

• An outcome is a result or consequence of physical therapy

intervention

• A functional outcome is one in which the effect of treatment is a

change in an individual's ability to accomplish a goal that is
meaningful for that individual.
• Functional outcomes should be the focus of physical therapy
documentation for the following reasons:
1. Examination procedures should determine relevant limitations in functional
activities and the impairments that cause those limitations.
2. Goals should be explicitly defined in terms of the functional activities that
the patient will be able to perform.
3. Specific interventions should be justified in terms of their effects on
functional outcomes.
4. Most important, the success of interventions should be measured by the
degree to which desired functional outcomes are achieved.
• Two main purposes:
1. To provide a framework for clinical decision making that is based on a
functional outcomes approach
2. To provide guided practice in writing functional outcomes documentation.
• The framework for documentation presented herein is based on the
widely accepted International Classification for Functioning, Disability
and Health (ICF) model of how pathologic conditions lead to disability.
• In 2008 the American Physical Therapy Association (APTA) joined the
World Health Organization (WHO), the World Confederation for
Physical Therapy, the American Therapeutic Recreation Association,
and other international organizations in endorsing the ICF model.
Concept of the Disablement
• Disablement, which describes the consequences of disease in terms
of its effects on body functions, the ability of the individual to perform
meaningful tasks, and the ability to fulfill one's roles in life.

• Saad Nagi (1965) developed one of the most influential models of

disablement
ICF Model
Definitions of the Components
of ICF
1. Body functions are physiologic functions of body systems (including
psychological functions).
2. Body structures are anatomic parts of the body such as organs,
limbs, and their components.
3. Impairments are problems in body function or structure such as a
significant abnormality or loss.
4. Activity is the performance of a task or action by an individual.
5. Participation is involvement in a life situation.
6. Activity limitations are difficulties an individual may have in
performing activities.
7. Participation restrictions are problems an individual may
experience in involvement in life situations.
8. Environmental factors make up the physical, social, and attitudinal
environment in which people live and conduct their lives.
• In the ICF model, the process of disablement is a combination of
1. Losses or abnormalities of body function and structure,
2. Limitations of activities,
3. Restrictions in participation
• Contextual factors—both extrinsic (environmental) and intrinsic
(personal)—are specifically identified as affecting the relationship
between body structures and functions and activities and
participation.
• Intrinsic personal factors can consist of such things as level of prior
education, coping style, and family support
• Extrinsic environmental factors might include social attitudes, architectural
barriers, and social/legal structures.
• ICF is part of the WHO family of international classifications, which
includes the International Statistical Classification of Diseases and
Related Health Problems (ICD).

• Until recently ICD-10 was the version used by health professionals in

the United States to classify diseases, disorders, or other health
conditions.

• In late 2015, a more complex set of codes, referred to as ICD-10, was

adopted for use in the United States.
 Rehabilitation Is Enablement:
The Reverse of
Disablement
• Rehabilitation is conceptualized as enablement: the reverse and
mirror image of disablement.
1. Whereas disablement begins with a disease/disorder, rehabilitation begins
with participation—specifying the desired result in terms of personal and
social roles the patient is attempting to achieve, resume, or retain.
2. These roles require the performance of skills or activities—from self-care to
household to community to occupation.
3. The therapist must determine how these skills are limited in such ways as to
prevent the fulfillment of the individual's roles.
4. Then the therapist must ascertain why the specified activities are limited by
determining the critical neuromotor and musculoskeletal mechanisms that
are impaired.
5. These mechanisms can be considered resources that can be used in the
performance of the skills.
Role of PTs
• A primary goal of physical therapy is to minimize participation
restrictions and activity limitations.
• Nevertheless, the emphasis on functional outcomes in documentation
should not be assumed to imply that PTs should focus exclusively on
measuring performance at the activity level and training in functional
skills.
• PTs are trained to determine the causes of movement dysfunction,
usually in terms of impairments of body structure/function.
• Ignoring or neglecting this aspect of physical therapy is as much a
fallacy as is neglecting functional outcomes.
• Ultimate goal of physical therapy is to promote health and recovery
from injury and disease.
 Functional Outcomes: More
Than Simply a
Documentation Strategy
• The method of documentation is based on two assumptions:

• (1) a primary purpose of physical therapy evaluation is to define the

specific functional outcomes that need to be achieved

• (2) the criterion for judging the effectiveness of treatment should be

whether those outcomes are achieved.
• The purpose of functional outcomes rehabilitation documentation is
to provide an explicit and prospective framework by which PTs can
• (1) analyze the reasons for disablement in their patients,
• (2) formulate enablement strategies for preventing or reversing that
disablement
• (3) explain and justify the resulting clinical decisions they make.
Classification According to the
ICF Framework
• Documentation requires the PT to develop skills in classifying the
various aspects of the patient's condition using the ICF as a
framework.
• The classification has two bases: the organizational level at which
function is observed and the level of measurement
• The observation that a patient has an infection of the femur (osteomyelitis) is
an example of pathologic information (at the tissue level, a health condition).
The health condition usually includes the nature of the pathology (e.g.,
infection, tumor), its location, and the timing relative to onset (i.e., acute
versus chronic).

• Weakness of the quadriceps muscle represents a reduction in a body

function (muscular); thus it is an impairment of body structure/function. It is
measured in the frame of reference defined by the body system's function.
The muscular system is defined by its ability to produce force over time.
Weakness is measured in terms of the force output possible in a defined set
of conditions.
• An inability to walk is defined as an activity limitation because it is a deficit in
the ability of the whole person to successfully perform an activity. Activity
limitations are measured in terms of performance or skill. Considering
whether—and to what degree—the goal of the activity has been attained is
an essential component of measuring performance at the activity level.

• A patient's inability to care for his or her child would be a participation

restriction. It is measured at the level of the individual's social interaction,
which can be quantified along three dimensions: (1) participation in desired
or expected social roles, (2) the level of assistance required to achieve that
participation, and (3) quality of life.
Classify each statement according
to the ICF model
 Essentials of
Documentation
Learning Objectives
1. Discuss the history of the medical record and documentation.
2. Identify the four basic types of physical therapy notes.
3. List the different purposes that documentation serves.
4. Discuss the pros and cons of different documentation formats.
5. Discuss the importance of using standardized assessments as part
of documentation, and describe the four types of standardized
measures commonly used.
6. Describe strategies for concise documentation.
7. Appropriately use and interpret common rehabilitation and medical
abbreviations.
8. Use people-first language in written and oral communication.
Types of Notes
1. Initial Examination/Evaluation (Written by Physical Therapist)
• Documentation of the initial examination/evaluation is required at onset of an
episode of PT care
• The initial evaluation should be a comprehensive report incorporating clinical
findings, review of history and medical conditions, assessment or evaluation
of the findings, and goals and a plan of care.
• The format for the initial evaluation should follow this general guideline,
which will be used throughout this text:
• Reason for referral
• Health condition
• Participation and social history
• Activities
• Systems review
• Impairments
• Assessment (including evaluation, diagnosis, and prognosis)
• Goals
• Plan of care
2. Session Notes (Written by Physical Therapist or Physical Therapist
Assistant) for Each Treatment Session

• The key components to be included in session notes are as follows:

1. Patient/client self-report
2. Specific interventions provided, including frequency, intensity, and duration
as appropriate
3. Changes in patient/client impairment, activity, and participation as they
relate to the plan of care
4. Response to interventions, including adverse reactions, if any
5. Factors that modify frequency or intensity of intervention and progression
of goals, including adherence to patient-related instructions
6. Communication/consultation with
providers/patient/client/family/significant other
7. Plan for ongoing provision of services for the next visit(s), which should
include the interventions
8. with objectives, progression parameters, and precautions, if indicated
3. Progress Notes (Written by Physical Therapist)
• The key aspects of a progress note are as follows:
1. Provide an update of patient status over a number of visits or certain
period
2. Include selected components of examination to update patient's
impairment, activities, and/or participation status
3. Provide an interpretation of findings and, when indicated, revision of goals
4. When indicated, include a revision of plan of care, as directly correlated
with goals as documented
4. Discharge Summary (Written by Physical Therapist)
• Discharge or discontinuation summaries are written at the completion of
services by a PT. The discharge summary provides a final report covering the
following information:
1. Current physical/functional status
2. The degree to which goals were achieved and reasons for any goals not
being achieved or partially achieved
3. Discharge/discontinuation plan related to the patient's continuing care and
recommendations including home program, referral for additional services,
family/caregiver training, and any equipment provided.
Purposes of Note Writing
• Documentation by the PT serves many purposes
1. Communication with Other Health Care Professionals
2. Communication with Health Care Administration
3. Communication with Third-Party Payers
4. Guide for Clinical Decision Making
5. A Legal Record
Documentation Formats
• Narrative Format
1. The simplest form of documentation recounts what happened in a
therapist-patient encounter.
2. In this format, therapists can, and should, develop their own outline of
information to cover.
3. These outlines can be more or less detailed. The specific information listed
in each heading is left to the writer's discretion, although some facilities
provide guidelines for what should be covered under each heading.
4. Because of the unstructured nature of narrative formats, the writer is
prone to omissions, and there can be a high degree of variability (both
within and among different writers).
5. Furthermore, if information is not included, it is assumed it was not tested,
whereas the writer may have inadvertently omitted the testing information.
6. Thus therapists must take particular care to be comprehensive in their
documentation to minimize inconsistencies and maximize accuracy.
• SOAP Format
• The SOAP note is a highly structured documentation format.
• In this type of medical record, each patient chart is headed by a numbered list
of patient problems (usually developed by the primary physician).
• When entering documentation, each professional would refer to the number
of the problem he or she was writing about and then write a note using SOAP
format.
• The SOAP format requires the practitioner to enter information in the order
of the acronym's initials: Subjective Objective Assessment
• Functional Outcome Report Format
1. The functional outcome report (FOR) format is a relatively new
documentation format.
2. The FOR format focuses on documenting the ability to perform meaningful
functional activities rather than isolated musculoskeletal, neuromuscular,
cardiopulmonary, or integumentary impairments.
3. When the format is implemented properly, FOR documentation establishes
the rationale for therapy by indicating the links between such impairments
and the participation restrictions to which they are related.
What Constitutes
“Documentation”?
• Documentation is any form of written communication related to a patient
encounter, such as an initial evaluation, progress note, session note, or
discharge summary.

• It encompasses the preparation and assembly of records to authenticate

and communicate the care given by a health care provider and the reasons
for giving that care.

• Documentation can take many forms, including written reports,

standardized assessments, graphs and tables, and photographs and
drawings.
1. Written Reports
• Most commonly, PTs use a written report to document their findings
from an evaluation or convey what has occurred in a patient visit.
• The format of this report can take many forms; the two most common
are a narrative format and a SOAP format.
• In this text, we use a narrative format for documenting an initial
evaluation
• . For progress notes and session notes, we recommend using a SOAP
format.
2. Graphs and Tables
• Graphs can be used as a form of documentation to provide a
visualization of a patient's progress in therapy.
•
3. Photographs, Drawings, and
Graphics
• Some aspects of patient care are difficult to describe narratively but
may be best explained visually.
• Photographs (obtained with the patient's written consent) can be
used very effectively for documenting impairments such as posture or
wound size or for documenting functional abilities.
Evidence-Based Practice
• Evidence-based practice be fully integrated into clinical
documentation.
• This is most important in documentation of the initial evaluation and
plan of care as well as during documentation of session notes, when
specific intervention strategies are reported.
• APTA recommends the following strategies for therapists to integrate
evidence-based practice in clinical documentation:
1. Documenting tests and measures that are valid and reliable for diagnostic
and/or prognostic information.
2. Use of standardized outcome measures, which are an effective means of
evaluating and communicating changes in a patient's/client's impairments
and/or functioning.
3. Selecting and implementing an appropriate plan of care and
interventions/treatments based on available research or clinical guidelines
and that reflect patient perspectives and preferences and their influence on
the plan of care (APTA, 2011).
Strategies for Conciseness in
Documentation
1. Concise Wording
• A written medical record has some specific characteristics that differentiate it
from traditional narrative writing.
• For example, medical documentation should be appropriately concise. Time is
often limited in health care settings; thus wordiness and undue lengthiness
should be minimized.
• One way to save time in medical documentation is by not using full sentence
structures and using abbreviations.
• Also, eliminating the words his, her, a, the, for, and an can improve readability
of a medical note.
2. Abbreviations and Medical Terminology
• The first question that must be addressed regarding use of abbreviations is,
“Who will be the reader of this note?”
1. Another physical therapist or physical therapist assistant (and no other
person)
2. Another professional (e.g., physician or nurse)
3. Nonprofessional (e.g., administrative staff, claims auditor, member of a
jury),
• Furthermore, if the writer is in doubt about the use of an abbreviation, it is
best to spell out the word.
• Furthermore, hospitals and health care facilities often develop their own list
of abbreviations that are considered acceptable in that institution, and those
lists are likely to be more encompassing than those listed here.

• PTs and PTAs should follow guidelines set by individual institutions when
considering the appropriateness of specific abbreviations.

• Certain types of documentation are intended for the primary readership of

the patient. For example, a home exercise program should be written in lay
terminology, avoiding abbreviations and medical jargon.
• Similarly, any documentation that is sent to third-party payers, and
particularly to patients or their families, should make more limited use of
abbreviations. If uncommon medical terminology is used, it should be defined
in layperson's terms
 List of Common Abbreviation
used in Rehabilitation

[Link]
rapy-abbreviations/

[Link]
/
3. Omit Unnecessary and Irrelevant Facts
• The best way to write clear, concise notes quickly is to avoid unnecessary and
irrelevant facts and conclusions.
• Merely because the therapist has observed something does not make it
appropriate to include in the note.
• The note should include only those observations and interpretations that are
essential for documenting the patient's current medical condition.
• Omitting nonessential items makes the note more readable and more
efficient to write.
• Therapists should generally avoid, or be very careful, when including
the following information in a medical note:
1. Detailed social history
2. Detailed living situation
3. Family history not directly related to current medical condition
4. Detailed history of other medical conditions that have been resolved and
do not affect the current condition
4. Use of Templates
• Templates are standard forms that therapists can use to essentially fill in the
blanks, and they are standard practice in most electronic medical records.
• Templates ensure that pertinent items are covered and provide a consistent
format for assessing different patients.
• Once the template is familiar to various professionals, pertinent information
can be located readily within the report.
• Electronic medical records have facilitated the use of such templates in which
therapists typically use a combination of narrative writing, check boxes, and
pull-down menus from a prefabricated template to develop an individualized
evaluation report
• If such forms are used, no line should be left blank. In this way, the evaluation
cannot be altered by another party without the therapist's knowledge. Also,
if a line is left blank, the reason it was left blank is unknown to the reader.
• The therapist must write one of the following on the line:
1. The results of the test, examination findings, or clinical opinion.
2. N/T (not tested), to indicate that this item was not tested. This entry in the note
should be followed by a reason the item was not tested or a plan for testing in the
future (e.g., “N/T 2° to time constraints—to be evaluated 11/1”).
3. N/A (not applicable), to indicate that this test was not applicable for this particular
patient given his or her diagnosis or condition. The therapist should state why the
test or measure is not applicable (e.g., “N/A—Pt. is currently on ventilator and
unable to get out of bed”).
Person-First Language
• People-first language is language that is used in oral or written
communication that describes the disease or medical condition a
person has without it defining who the person is.

• Terms such as autistic, mentally retarded, and paraplegic all focus on

defining a person by his or her disability.

• The APTA supports the use of people-first language, as described in

Terminology for Communication about People with Disabilities
Key Points in Writing People-
First Language
• Put People First Not Their Disability
• Say a woman with arthritis, not an arthritic woman. This puts the focus on the
individual and not on their disability or medical condition.

• Emphasize Abilities, Not Limitations

• Using the phrase: Walks with leg braces, or uses a wheelchair for long-
distance mobility, is more accurate and positively focused than confined to a
wheelchair or wheelchair bound.
• Avoid Negative Labelling
• Saying afflicted with, crippled with, victim of or suffers from devalues
individuals with disabilities and portrays them as more helpless and defined
by their disability.

• Avoid Derogatory Statements

• Avoid derogatory statements about patients, such as Patient complains of…
Rather state Patient reports…
Interpreting Abbreviations
Legal Aspects of
Documentation
Learning Objectives
1. List and describe the key aspects of physical therapy documentation as a
legal record.
2. Use the correct method for signing notes and correcting errors in
documentation.
3. Describe the Health Insurance Portability and Accountability Act (HIPAA)
and the Privacy Rule, and discuss the implication for physical therapy
documentation.
4. Discuss the importance of appropriately documenting informed consent
as part of a physical therapy evaluation.
5. Discuss the three legal reasons why a physical therapist's documentation
may be scrutinized.
Documentation as a Legal
Record
• Documentation in a medical record is a legal document.

• A physical therapist (PT) should take his or her documentation very

seriously and understand that documented notes may be scrutinized
not only for payment of services but also for legal reasons.

• PTs should be familiar with their individual state practice acts to

ensure they are in compliance and that their documentation reflects a
practice that is within the legal description provided by their state.
Important Definitions
1. Audit: a detailed review and evaluation of selected clinical records by
qualified professional personnel for evaluating quality of medical care.
2. Authentication: identification of the author of a medical record entry by
that author and confirmation that the contents are what the author
intended.
3. HIPAA Privacy Rule: a component of a law passed in 1996 that is
designed to protect the privacy of health care data and to promote more
standardization and efficiency in the health care industry.
4. Informed consent: a voluntary, legally documented agreement by a
health care consumer to allow performance of a specific diagnostic,
therapeutic, or research procedure.
5. Malpractice: negligence or misconduct by a professional person, such as a doctor
or physical therapist. The failure to meet a standard of care or standard of
conduct that is recognized by a profession reaches the level of malpractice when
a client or patient is injured or damaged because of error.
6. Medical necessity: services or items reasonable and necessary for the diagnosis
or treatment of illness or injury or to improve the functioning of a malformed
body member.
7. Notice of privacy practices (NPP): a notice or written document given to a health
care consumer that explains the privacy policies related to his or her medical
records. All patients must sign a statement acknowledging receipt of the NPP.
8. Third-party payer: an organization other than the patient (first party) or health
care provider (second party) involved in the financing of personal health services.
 Key Legal Aspects of Physical
Therapy Documentation
• Legibility
• Handwritten entries should be legible and written in ink. Many third-party
payers, including Medicare, include legibility in their payment policy describing
reasons for nonpayment.
• For this reason, electronic documentation is often recommended to eliminate
this potential concern.

• Dated in Month/Day and Year Format

• All notes must be dated with the date the note was written. Backdating is illegal
and should never be done.
• It is recommended that all notes be written or dictated on the date that an
evaluation or intervention is performed.
• Authentication
• All physical therapy documentation must be authenticated by a PT or, when
appropriate, a physical therapy assistant (PTA).
• All notes must be signed, followed by the provider's professional designation,
and dated.
• The American Physical Therapy Association House of Delegates (APTA, HOD,
2014, P06-03-17-14) has recommended use of standard professional
designations: PT for physical therapists and PTA for physical therapist
assistants
• Degrees and Certifications
• The APTA supports the following preferred order when a therapist or assistant
has additional degrees or certifications The preferred order is as follows:
1. PT/PTA
2. Highest earned physical therapy–related degree
3. Other earned academic degree(s)
4. Specialist certification credentials in alphabetical order (specific to the American Board
ofPhysical Therapy Specialties).
5. Other credentials external to APTA
6. Other certification or professional honors (e.g., FAPTA)
• PTA Authentication
• PTAs should sign any record where they participated in any aspect of the
delivery of the service the documentation describes.
• Although all evaluations must be documented and signed by a physical
therapist, if a PTA, for example, takes and documents measurements as part
of the PT's evaluation, the PTA should sign the record indicating this was
done.
• Student PT and PTA Authentication
• Student PTs (SPTs) or student PTAs (SPTAs)—individuals who are enrolled in a
PT or PTA educational program—are allowed to write notes in the medical
record.
• These notes must be signed and dated by the student and also must be
authenticated by a supervising licensed PT or PTA
• Errors
• If an error is made in a handwritten note or a printed copy of an electronic
note, the therapist should place a single line through the erroneous word and
write his or her initials near the crossed out word.
 Privacy of the Medical Record:
HIPAA and the Privacy Rule
• HIPAA stands for the Health Insurance Portability and Accountability
Act.

• There are two parts to the law.

1. The first part is involved with the portability of an individual's health care
insurance in the event of a job loss.
2. The second part, which is pertinent to medical documentation, was
designed to protect the privacy of health care data and to promote more
standardization and efficiency in the health care industry.
• The Privacy Rule “address[es] the use and disclosure of individuals'
health information—called protected health information (PHI) by
organizations subject to the Privacy Rule— called covered entities as
well as standards for individuals' privacy rights to understand and
control how their health information is used”
• Some basic guidelines for covered entities for maintaining patient privacy
of medical records are as follows:
1. Patients must be given a notice of privacy practice (NPP) document, which
explains the privacy policies related to their medical records. All patients must
sign a statement acknowledging receipt of the NPP.
2. Therapists must obtain a patient's consent to access, use, or disclose any
personally identifiable health information for purposes of treatment, payment,
and health care operations (TPO).
3. A patient's medical record should never be disclosed to a third party (including
employers and family members) without specific permission from the patient.
4. Parents or guardians must grant approval for access to a minor's medical
record.
• The APTA Defensible Documentation ([Link]) recommends
several general strategies for maintaining patient confidentiality,
including the following:
1. Keep patient documentation in a secure area.
2. Keep charts facing down so the patient's name is not displayed.
3. Never leave patient charts unattended.
4. Do not discuss patient cases in open or public areas.
Potential Legal Issues
• Malpractice
• Malpractice suits against therapists, although rare, typically occur when an
accident happens in the course of a therapy session.
• A patient who is recovering from an ankle injury could overexercise in therapy
and reinjure the affected area, for example.
• Alternatively, a patient who has had a stroke could fall and sustain a fracture
during gait training or transfer training.
• Keeping comprehensive and up-to-date medical records is critical to
minimizing liability risk.
• Documentation When Lawsuits are Involved
• A patient may be involved in a lawsuit related to an accident that he or she
had, such as a workplace accident or a motor vehicle accident.
• In such cases the PT's records will serve as a legal record and will be
scrutinized to determine the necessity of the intervention and the degree of
impairments and activity limitations for a patient that are a direct result of
the incident that is the subject of the lawsuit.
• Fraudulent Charges
• When billing third-party payers, the PT's medical records will be examined to
determine whether the interventions provided match the billing for those
interventions.
• If the PT charges for something that was not done or not supported by
documentation, legal action can be taken on the part of the third-party payer.

• Preventive Actions
• A therapy practice or facility can take several actions to minimize the risk of
an audit by a thirdparty payer or government agency or other legal action.
Electronic Medical
Record
Learning Objectives
1. Identify and describe the benefits of an electronic medical record.
2. Discuss the various uses of patient data obtained from
computerized documentation systems.
• The Health Information Technology for Economic and Clinical Health
(HITECH) Act of 2009 was passed to promote the adoption of electronic
health records (EHRs)

• Physical therapists (PTs), regardless of the setting in which they work,

are key members of the patient care team.

• Communication between practitioners in the health care environment

has often been a challenge. Meaningful use requirements, as part of an
EHR, will help facility communication among health care practitioners.
Evidence for Electronic Medical
Records
• Wu and Straus (2006) report improved documentation in terms of patient encounter
time, more use of standard variables, and improved diagnostic accuracy using a
handheld EMR compared with a paper-based system in an orthopedic practice.

• Several nursing articles have discussed the benefits of the EMR for completeness of
nursing documentation as perceived by the physician (Green & Thomas, 2008) and
have reported a slight decrease in routine nursing documentation time (Hakes &
Whittington, 2008), although the finding approached but did not reach significance.

• El-Kareh et al. (2009) reported that although clinicians may perceive some initial
problems with a new electronic health recording system, they are significantly more
receptive to it within 1 year of its implementation.
Electronic Records in Physical
Therapy Practice
• Drawbacks to Pen and Paper Documentation
1. Legibility of the notes.
2. Redundancy of medical and demographic information.
3. Difficulty with data retrieval for clinical research or outcomes analysis to
promote evidence-based practice.
4. Use of abbreviations
Benefits of Computerized Documentation
1. Standardization of data elements and charting practices
2. Elimination of redundancy and reduction of errors
3. Accessibility of data in real time
4. Cost efficiency
5. Facilitated documentation of outcome measures
6. Improved legibility of the medical record
7. Decreased space requirements for storing medical records
8. Improved confidentiality of the medical record
Drawbacks of Electronic
Documentation
1. The primary drawback to the use of an automated documentation
system is the initial financial investment, the development time,
and the need for staff training.
2. An automated electronic rehabilitation system can cost millions of
dollars.
3. Additional expenses include the time for staff development of the
software.
4. Some software systems provide “canned” documentation tools with
the ability to modify them, whereas others allow the flexibility for
total customization but require time and resources for development
Uses of Patient Data from
Electronic Medical Records
1. Individualized Patient Reports
2. Aggregated Patient Data
3. Case Mix Indexing
4. Regulatory Requirements
5. Marketing