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"I think it, but don't often write it": the barriers to charting in private practice
Katherine Harman1, Raewyn Bassett, Anne Fenety
1School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia. k.harman@dal.ca
Physiotherapy Canada. Physiotherapie Canada
|September 3, 2010
Summary
Physiotherapists face challenges integrating charting into client care due to the mismatch between clinical reasoning and documentation. Addressing these barriers is crucial for improving the quality of physiotherapy records.
Area of Science:
- Physiotherapy
- Health Services Research
- Clinical Documentation
Background:
- Charting is essential for quality patient care and professional accountability in physiotherapy.
- Private practice physiotherapists may encounter unique challenges in documentation.
- Understanding these challenges is key to developing effective support strategies.
Purpose of the Study:
- To identify and describe the barriers encountered by physiotherapists in private practice regarding clinical charting.
- To explore the experiences of physiotherapists in New Brunswick concerning documentation practices.
Main Methods:
- Qualitative study involving focus-group interviews with physiotherapists.
- Thematic analysis of transcribed interviews from 49 participants across nine focus groups.
- Data collected following a comprehensive chart audit.
Main Results:
- Key barriers include the disconnect between clinical thinking and charting, difficulty translating impairment to functional goals, time constraints, fear of failure, and predicting treatment length.
- Participants identified strategies to improve the charting process.
- The implicit nature of clinical reasoning conflicts with the explicit requirements of written documentation.
Conclusions:
- Improving the quality of physiotherapy documentation requires understanding and addressing identified charting barriers.
- The tacit, cognitive processes of clinical reasoning are often mismatched with the explicit demands of charting.
- Further profession-wide discussion and strategy development are needed to facilitate effective charting practices.
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