11-2 Guidelines for Information Management in Physical Therapy

Guidelines for Information Management in Physical Therapy in Light of Legal and Ethical Issues
Yaron Tillinger, BPT, MA

Abstract

The aim of this article is to demonstrate that ethical and legal issues can provide guidelines for designing medical records in the field of modern medicine in general and the field of physical therapy in particular. Some of the changes that have taken place in the field of medicine will be presented. These changes mandate a rethinking of the structure and organization of the medical/physical therapy record. This article will demonstrate how the medical ethics debate is an important tool in decision making for this topic.

The article includes the following topics:

1. A review of the modern principles of bio-ethics. Presented are two models that exist side by side in the American and European continents and the way in which the Israeli bioethical world needs to balance itself between these two models that represent two different world views.

2. The change in the relation between the medical profession and the client as it has become less paternalistic and more egalitarian. The article presents the implications of this development on medical record keeping.

3. The issue of the “duty to warn” as an example of situations in which there is a need to combine the right for privacy with an individual’s needs to give up autonomous control over his/her medical records.

4. The relationship between medical malpractice and medical record keeping.

5. Statutory requirements relating to administration, documentation, and storage of medical information, as well as the required level of detail, as seen in various laws – especially the Israeli Law of Patient Rights (1996).

Key words: medical record keeping, medical ethics, paternalism, equality, documentation, duty to warn, responsibility, patient, medical professional.