Improving Orthopaedic Assessment in a Physiotherapy Department

The writer’s physiotherapy department has 36 therapists who graduated from 12 different national and international universities. This has caused diversity in assessment and documentation procedures. A literature review showed that professional and standardised documentation is vital for the creation of patient care plans, enhances communication, and is a legal requirement. In addition, the generated data can be used for research purposes. Moreover, research has shown that the use of forms is associated with significantly higher documentation rates. The World Confederation for Physical Therapy published the Core Standards of Physiotherapy Practice and recognised the importance of developing assessment forms that suit the prevailing circumstances in organisations. This change project used a modified HSE change model. The in-service team formulated seven orthopaedic assessment forms and conducted training lectures to enhance employees’ knowledge and skills. The post-change audit revealed a compliance rate of 38% in the use of the forms. Furthermore, the subjective and objective documentation rates significantly improved after training sessions. The organisation is working to computerise the documentation of the assessment forms to further improve the documentation and assessment procedures.