Electronic Clinical Records for Physiotherapists

Abstract
Purpose: This pilot study compared traditional (paper-based) and electronic (computerized) clinical physiotherapy records. The content of the records and the software’s user acceptability were considered. Methods: A neuro-musculoskeletal patient scenario involving two encounters (initial and follow-up) was scripted and role-played to each of three experienced physiotherapists (A, B and C). Participants assessed the patient and made traditional clinical records. After basic training in an electronic record system, they repeated the assessments and made electronic records via a laptop computer. Three experienced physiotherapists (A, D and E) each used their usual method to write a clinical report and an electronic record to write a report with the aid of the software’s report tool. The two participants who wrote reports but did not assess the patient (D and E) received a brief software demonstration just prior to writing the electronic record report. The electronic and traditional clinical records and reports were compared regarding their content and completion time. Participants recorded their expectations and experience of learning and using the electronic record system via questionnaires. Results: Participants expressed initial apprehension regarding an unfamiliar documentation system, but generally found the electronic system easy to learn and use. Some would have preferred additional customization options. All traditional records contained pages that lacked patient identification details. The electronic records contained more details related to symptoms, social circumstances and physical examination findings. The participants used more time for assessment and recording the initial examination when using the electronic system. Participants reported easier data retrieval from the computerized records than from the traditional records. Conclusions: The electronic clinical record system may prompt more complete recording and facilitate better patient record identification. These effects have implications for patient care, communication between providers and clinicians’ medico-legal protection. Further research is needed to determine the system’s efficiency and to clarify the impact of other characteristics of electronic record systems for physiotherapists.