This article aims to highlight the importance of a complete and accurate medical record as it pertains to potential risk exposure in the outpatient physical therapy profession.
Basic charting rules, correction and alteration recommendations, documentation of telephone conversations, informed consent, exculpatory release forms and incident reports are discussed. Basic risk management strategies are reviewed that may reduce outpatient physical therapy practitioners' malpractice exposure.
The authors contend that quality and thorough documentation is as important as the quality of the care that is delivered to patients, since medical records are legal documents and serve as valuable evidence as to what transpired between patients and the healthcare providers.
Practical documentation strategies are described in a manner that will inform physical therapists of their legal obligations relating to patient care.
