الفهرس | Only 14 pages are availabe for public view |
Abstract Background: Documentation is the process of recording of all aspects of Patient care, management including the results of the initial examination, diagnosis, prognosis, plan of treatment, interventions, response to interventions, changes in Patient relative to the interventions, re-examination, and discharge. Aim of study the current study examined the quality level of clinical record and documentation of pediatric physiotherapy departments at teaching hospitals and institutes according to the criteria of the Physical Therapy chartered Society Standards to determine points of documentation lacking and work on solving them to improve the quality of record and documentation in medical institutions. MaterialandMethods. This study was carried as Cross-sectional study at teaching hospitals and institutes for 310 patient record files which were selected randomly from Faculty of physical therapy outpatient clinic 100), The National Institute of Neuromotor system (100), Elmatarya Teaching Hospital (100) and Elsahel Teaching Hospital (10). Assessment of the quality of patient record files was carried out by using of the standardized patient record audit approved by the chartered Society Standards. To describe, assess and report the quality of the working system |