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Le dossier du patient en masso-kinésithérapie - Patients records in physiotherapy - Guidelines

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Posted on Mar 01 2000 These guidelines describe what a physiotherapy patient record should contain. Posted on Mar 01 2000

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Christian VIADE, physiotherapist, Lille;READING GROUP
Éric VIEL, physiotherapist, Thonon;
Christian ABALEA, physiotherapist, Besançon; Mme. Geneviève VILLARET-SAMIER, orthopaedic specialist, Lille;
rD Jean-Jacques AKNIN, orthopaedic specialist, Villeurbanne; Alain YELNICK, doctor of physical medicine and rehabilitation, Paris;
r rD Gérard ALEXANDRE, orthopaedic surgeon and doctor of physical medicine and rehabilitation, Paris; D YVAIN, geriatrician, Ivry-sur-Seine.
Christian ALLEZOT, physiotherapist, La Membrolle-sur-Choisille;
rD René AUSSEDAT, rheumatologist, Nancy;
rD Laurent BARREAU, general practitioner, Saint-Père-en-Retz;
Mme. Véronique BILLAT, physiotherapist, Neufchâteau; GUIDELINES
Marc BLANC, physiotherapist, Le Port-Barcarès;
Professor Pierre BOURGEOIS, rheumatologist, Paris;
The working group recommends that all physiotherapists (both em-Mme. Corinne BOURIGAULT PRELLE, occupational therapist, Sainte-Foy-l’Argentière;
rD Frédérique BRUDON, neurologist, Villeurbanne; ployed and freelance, irrespective of their type of activity) should start
Professor Bernard BUSSEL, neurologist, Garches; a record for every patient and keep it up to date.
rD Jean-Loup CARTIER, orthopaedic surgeon, Gap;
rD Catherine DAL ZOTTO, geriatrician, Nice; It is recommended that, as far as possible, this record should be incorporat-
Éric DECHAMPS, orthopaedic specialist, Villiers-Saint-Denis;
ed into a medical record or into a single record designed to be used by all
Jean DELEPINE, charge nurse, Ballan-Mire;
healthcare personnel.Jean-Pierre DENTZ, physiotherapist, Stains;
rD François DESTOMBES, chest physician, Le Havre;
r It is recommended that the record be designed in such a way that it isD Jean-Pascal DEVAILLY, doctor of physical medicine and rehabilitation, Bobigny;
rD Olivier DIZIEN, doctor of physical medicine and rehabilitation, Garches; appropriate for the procedures, the activity and the context of each pro-
François DUCROS, physiotherapist, Strasbourg; fessional or care centre. However, the following rules should be ob-
rD Jean-Marc DUMEIX, chest physician, Chalon-sur-Saône;
served:rD Benoît DUQUESME, chest physician, Liévin;
– the person who completes the record should be identified;Mme. Brigitte DUSSO, nurse, Andelot-en-Montagne;
rD Pierre FERRU, general practitioner, Gencay; – the record should be structured and simple to use;
Professor Vincent GAUTHERON, doctor of physical medicine and rehabilitation, Saint-Étienne; – it should use precise, clear language and an understandable vocabulary;rD Bernard GAY, general practitioner, Rions, member of the ANAES Scientific Council;
– it should contain information specific to the practice of physiotherapy;Jean-Luc GERARDI, physiotherapist, Lattes;
Mlle. Chantal GERIN, occupational therapist, Pierre-Bénite; – record management should preserve the confidentiality of patient data.
Mme. Brigitte GOBERT, physiotherapist, Roubaix;
A physiotherapy patient record should contain the following informa-Dominique GRASSER, physiotherapist, Besançon;
rD Jean-Pierre HOCHART, rheumatologist, Étaples; tion:
Édouard-Guy LECLERC, physiotherapist, Le Havre;
rD Jacques LECUREUIL, rheumatologist, Joué-lès-Tours; 1. Social and administrative information
rD Yves LEQUEUX, general practitioner, Saint-Père-en-Retz; Record number Desirable
Mlle. Lucienne LETELLIER, physiotherapist, Paris; Surname RequiredrD Bernard MAZIERES, rheumatologist, Toulouse;
First name RequiredrD Danièle MEYER-FLECK, doctor of physical medicine and rehabilitation, Colmar;
r Sex RequiredD Bernard MONTAGNE, neurologist, Roubaix;
Date and place of birth RequiredJean-François MULLER, physiotherapist, Mulhouse;
rD Alain NYS, doctor of physical medicine and rehabilitation, Neuilly-sur-Seine; Address Required
Mme. Christine ORVOINE, occupational therapist, Rennes; Telephone Desirable
Michel POUJADE, physiotherapist, Toulon Naval; Profession Required
rD Bernard PRALLET, rheumatologist, Saint-Étienne; Family situation DesirablerD Christiane PRIVAT-PAIN, doctor of physical medicine and rehabilitation, Malakoff;
Environment - lifestyle DesirableMme. Agnès RABOLIN, speech therapist, Besançon;
r Sports and other activity DesirableD Philippe RICHARD, general practitioner, Compertrix;
Name of person insured RequiredClaude-André RICHET, physiotherapist, Montreuil;
rD Éric ROLLAND, orthopaedic specialist, Paris; Social Security number Required
Patrick ROTGER, physiotherapist, Saint-Maurice; Person to contact (father, mother, guardian, etc.) Desirable
rD Bertrand ROUSSEAU, doctor of physical medicine and rehabilitation, Nantes; Details of private health insurance Desirable
Jacques ROUSTIT, speech therapist, Paris; Date of request for reimbursement, made prior to treatment (DEP) Desirable
Jean-Joachim ROYES, physiotherapist, Saint-Martin-d’Aubigny;
Method of transport DesirableMme. Évelyne SABOT, physiotherapist, Saint-Étienne;
Date of first session RequiredMme. Maryse SAINSON, physiotherapist, Avon;
rD Guy SALFATI, general practitioner, Autun; Date of last session Required
rD Jacques SAMUEL, rheumatologist, Paris; Name of physiotherapist Required
rD Patrick SEGAUD, general practitioner, Niort; Others involved Desirable
rD Claude SICHEL, general practitioner, Carnoux-en-Provence;
Jean SIGNEYROLLES, physiotherapist, Paris; 2. Medical information
Philippe STEVENIN, physiotherapist, member of the ANAES Scientific Council, L’Etang-la-ville; Medical diagnosis Required
Dominique-Louis TIQUET, occupational therapist, Ivry-sur-Seine; History of the disease Required
Mme. Yvonne TOURNIER, instructor in movement, Rennes;
r Medical problem(s)D Guy VANCON, rheumatologist, Bainville-sur-Madon;
r – requiring admission to hospital RequiredD Philippe VASSEL, doctor of physical medicine and rehabilitation, Coubert;
r – requiring physiotherapy treatment RequiredD Emmanuel VASSEUR, geriatrician, Angers;
rD Jean-Michel VERRET, neurologist, Le Mans; – other medical problem(s) DesirableHistory avec la participation de
medical Desirable
surgical
physiotherapy Desirable
family
Reports
examinations (imaging, functional investigations, etc.) Required
surgical
hospitalisation Desirable
consultation
Current treatment Desirable
Medical prescription of physiotherapy treatment Required
Prescribing doctor
3. Patient’s expectations Required
4. Physiotherapy examination Required CLINICALContaining sheets for updated assessments
(names of patient and physiotherapist given) PRACTICE
5. Physiotherapy diagnosis Required GUIDELINES
6. Aims of physiotherapy treatment Required
Including in particular: PATIENTS RECORDS– treatment objectives and priorities
– deadlines by which the objectives set are expected to be achieved
7. Physiotherapy treatment Required IN PHYSIOTHERAPY
This contains details of the physiotherapy treatment:
– therapeutic, preventive and educational strategy
– techniques described according to the nomenclature générale des actes profes-
sionnels (official French classification of items of treatment) or PMSI codes (Pro-
gramme de Médicalisation du Système d’Information - official French medical
management program)
The keeping of a treatment session record card for follow-up is recommended.
8. Results of treatment – Evaluation Required February 2000
9. End of treatment report Required
10. Professional correspondence Required
WORKING GROUP
Professor Francis GUILLEMIN, epidemiologist, Vandœuvre-lès-Nancy,The record should be accessible at all times during treatment.
Chairman of the working group;The working group recommends that the record should be the focus for
Jean-Michel LARDRY, physiotherapist, Dijon, working group project manager;
handwritten or computer communication involving the patient, the Vincent BACCIALONE, orthotist and prosthesist, Mulhouse;
referring doctor and other health care and social care personnel Jean-Pierre BERTHELIN, physiotherapist, Saint-Saturnin-le-Mans;
Mme. Françoise BIZOUARD-NOURDIN, physiotherapist, Paris;involved.
Professor Christian BREGEON, rheumatologist, Angers;
Jacques CHARMASSON, chest physician - allergologist, Pont-d’Héry;
Yves CHATRENET, physiotherapist, Plateau-d’Assy;
Jean-Louis ESTRADE, physiotherapist, Revilly;
rD Pierre-Christian GOEPFERT, doctor of physical medicine and rehabilitation, Vandœuvre-lès-Nancy;
Philippe HUGEROT, physiotherapist, Firminy;
Mme. Marie-Hélène LEMONNIER, psychologist, Garches;
The full report: ISBN: 2-910653-68-4 (Net price: 15,25 € - 100,00 FF) is available from Philippe PAUMARD, physiotherapist, Paris;
rAgence Nationale d’Accréditation et d’Évaluation en Santé (ANAES) D Pierre-François PRADAT, neurologist, Paris;
rD Gilberte ROBAIN, doctor of physical medicine and rehabilitation, Ivry-sur-Seine;Service Communication et Diffusion
Mme. Odile SERAPHIN, occupational therapist, Lyon;159, rue Nationale – 75640 Paris Cedex 13 – FRANCE
rD Philippe THOUMIE, doctor of physical medicine and rehabilitation, Paris.
Send a written order together with a cheque made out to
« l’Agent comptable de l’ANAES » MANAGEMENT COMMITTEE
Professor Pierre BOURGEOIS, rheumatologist, Paris;The full report can be downloaded for free from the ANAES website:
Professor Bernard BUSSEL, neurologist, Garches;www.anaes.fr or www.sante.fr
Éric VIEL, physiotherapist, Thonon.