Treatment Documentation in Practice-Based Evidence Research for Patients Receiving Physical Therapy Due to Lymphedema

Publication date: Available online 26 January 2019

Source: Archives of Physical Medicine and Rehabilitation

Author(s): Dorit Tidhar, Daniel Deutscher, Susan D. Horn, Jane M. Armer

Abstract

Objectives

To describe development and testing of a physical therapy treatment code documentation taxonomy.

Design

Clinician survey within a practice-based evidence (PBE) study framework for patients with lymphedema.

Setting

Outpatient physical therapy clinics within a large public healthcare service using a central electronic medical record.

Participants

Forty-three certified lymphedema therapists (CLTs).

Intervention

Treatment coding of 10 treatment vignettes representing real-life clinical scenarios. CLTs were asked to accurately select 35 activity-intervention combination codes.

Main outcome measures

The CLT score represented percentage of treatment codes accurately selected by each therapist. The code score represented percentage of CLTs who accurately selected each treatment code.

Results

The mean CLTs score was 91%, with 72% CLTs meeting the 90% criterion. Personal feedback was provided to each CLT. The mean code score was also 91%; with 71% of treatment codes meeting the 90% criterion. We identified 9 low-score codes needing additional education or found to be redundant. These codes were either clarified or removed.

Conclusions

The proposed treatment code documentation system for lymphedema therapy was found to be clear and accurately used by most CLTs. Specific needs for improvement were identified. Follow-up testing is warranted to ensure ongoing accurate implementation of the treatment documentation system.

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