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 phys-iotherapy 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.
Material and Methods: This study was carried as Cross-sectional study at teaching hospitals and institutes for 310 patient record files which were selected randomly from Elmatarya Teaching Hospital (100) The National Institute of Neuromotor system (100), Faculty of physical therapy outpa-tient clinic (100) and Elsahel Teaching Hospital (10). Assess-ment 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.
Results: There are statistically significant differences among the teaching hospitals and institute in the Assessment, Examination, Analysis, Implementation, Transfer of care discharge, Documentation and Patient record conform to the following requirements axes, however there is critical lacking in the axis of documentation of informed consent, evaluation and treatment planning. There is no information technology system for the patient record files at all Teaching Hospitals and Institute.
Conclusion: Using of the standardized patient record are not implemented in the included the Egyptian Pediatric Phys-ical Therapy Departments at Teaching Hospitals and Institute. There is no using of electronic medical records.