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Patient records – Physiotherapists’ contributions

This article presents the major findings of a study in which contributions made by physiotherapists in patients records are subjected to a content analysis. The text material is collected from three wards in a Norwegian hospital (neurology, orthopaedic and rheumatology wards), and consists of 67 records. This material is supplemented by interviews with the therapists. The study documents pronounced differences at the ward level, and the material as a whole represents the extremes. Certain records contain comprehensive notes about the individual patient's functional status and the therapy given, including adjustments to the individual patient (from the neurology and partly from the rheumatology ward). Other records are fairly standardized and scanty with a view to functional relationships and clinical assessments (from the orthopaedic and partly from the rheumatology ward). The article provides general overviews as well as detailed analyses of the text material. In accordance with the study's chosen focus, most emphasis is placed on findings that communicate distinctive features of physiotherapy as a clinical and professional endeavour. The author calls for reflection on the relationship between actual practice and the documentation of it, and relates the findings of the study to the current climate of accountability in the healthcare sector.