Level of completeness of documentation using problem oriented medical records approach done by the De La Salle Health Sciences Campus, College of Physical Therapy interns batch 2008 among patients with scoliosis
Date of Completion
2008
Document Type
Thesis
Degree Name
Bachelor of Science in Physical Therapy
Keywords
Medical Records, Scoliosis, Documentation, Physical Therapy
Abstract
Objective: to identify the level of completeness in making documentation using POMR done by the Physical Therapy Interns as to: a. DATABASE which includes General Data, History of Present illness, Past Medical History, Family History, Personal, Social, environment History, General Survey, Back & Spine, Special Test and Postural Analysis. b. PROBLEM LIST, c. INITIAL PLAN, D. PROGRESS NOTES. Research Design: This is a descriptive study that aims to determine the level of completeness of documentation using Problems Oriented Campus, College of Physical Therapy Interns Batch 2008 among patients with scoliosis. Setting: The study was conducted in De La Salle University Medical Center at Musculoskeletal Unit. Participants/Respondents: The researcher's reviewed documentations using the POMR approach of previous scoliosis patients that was handled by the Physical Therapy Interns batch 2008. Procedure/Interventions: The researchers of the study conducted a self made checklist to determine the level of completeness of CPT Interns Batch 2008 in making a documentation using POMR approach of scoliosis patient. The checklist was based on information gathered was determined using the following scale based on a study by Colocado et. al (2008) regarding the level of knowledge and common practices in proper body mechanics among factory workers in Optia LTD. INC. Result: The 45 documents that the researchers reviewed had 76.86% completeness as to database which interpreted to a very satisfactory level of completeness. The problem list had a 67.41% completeness that interpreted as a very satisfactory level of completeness. And the initial plan was graded to have a 76.44% completeness interpreting to a very satisfactory level of completeness. And the least component of the POMR format had 86.94% completeness which is excellent in making Scoliosis documentation which is a very satisfactory level of completeness. Conclusion: The result of the study showed that the College of Physical Therapy Intern's batch 2008 had a Very Satisfactory level of completeness in making POMR documentation of scoliosis patient
APA Citation
Antiquiera, K. B., Espino, N. J. L., Garcia, X. C., Real, A. R. A., & Villero, M. (2008). Level of completeness of documentation using problem oriented medical records approach done by the De La Salle Health Sciences Campus, College of Physical Therapy interns batch 2008 among patients with scoliosis. [Bachelor's thesis, De La Salle Medical and Health Sciences Institute]. GreenPrints. https://greenprints.dlshsi.edu.ph/bspt/225/