Dokumentation: das Spiegelbild professioneller Therapie

 

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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.

Publication History

Article published online:
12 September 2022

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

• 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
  Google Scholar
• 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
  Google Scholar
• 3 Australian Physiotherapy Association (APA). Guidelines for writing clinical notes. APA 2018. Im Internet: Accessed June 17, 2022 at: https://australian.physio/tools
  Google Scholar
• 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
  Google Scholar
• 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/
  Google Scholar
• 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
  Google Scholar
• 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
  Google Scholar
• 8 O’Sullivan SB, Schmitz TJ, Fulk G. Physical Rehabilitation. 7th ed.. Philadelphia: F. A. Davis; 2019
  Google Scholar
• 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 DOI: 10.1186/s12877-019-1201-4.
  CrossrefPubMedGoogle Scholar
• 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 DOI: 10.1016/j.physio.2014.11.003.
  CrossrefPubMedGoogle Scholar
• 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 DOI: 10.1007/s10198-004-0264-z.
  CrossrefPubMedGoogle Scholar
• 12 Fairbank JC, Couper J, Davies JB. et al. The Oswestry Low Back Pain Disability Questionnaire. Physiotherapy 1980; 66: 271-273
  PubMedGoogle Scholar
• 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 DOI: 10.1515/ijhp-2015-0002.
  CrossrefGoogle Scholar
• 14 Huhn K, Gilliland SJ, Black LL. et al. Clinical Reasoning in Physical Therapy: A Concept Analysis. Phys Ther 2019; 99: 440-456 DOI: 10.1093/ptj/pzy148.
  CrossrefPubMedGoogle Scholar
• 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 DOI: 10.1055/a-1113-6688.
  Article in Thieme ConnectGoogle Scholar
• 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 DOI: 10.1016/j.cptl.2017.03.010.
  CrossrefPubMedGoogle Scholar
• 17 Santiago LM, Neto I. SOAP Methodology in General Practice/Family Medicine Teaching in Practical Context. Acta Med Port 2016; 29: 854-859 DOI: 10.20344/amp.8405.
  CrossrefPubMedGoogle Scholar
• 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
  CrossrefPubMedGoogle Scholar
• 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
  PubMedGoogle Scholar
• 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 DOI: 10.1002/art.23563.
  CrossrefPubMedGoogle Scholar
• 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
  Google Scholar