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

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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