| Summary: | Neðst á síðunni er hægt að nálgast greinina í heild sinni með því að smella á hlekkinn View/Open Physical therapy and documentation have a long history and descriptions exist of treatments that physical therapists use, even today, from the year 2600 BC. There is a long tradition for paper and electronic documentation within the physical therapy domain in Iceland, although there is not a strong tradition for standardized documentation. Documentation is the means of communicating information from the professional to all „users“ and „readers“ of the medical record. It is „what“ therapists do and „how“ it is performed. It has even been stated that effective patient care documentation is as important as the delivery of care itself. The Directorate of Health in Iceland recommends the use of the classifications ICD, ICF, NCSP, NANDA and NIC. Many classifications and terminologies exist today mostly because physicians and nurses have been active in developing them for the last 40-60 years. The National Institute of Health in the USA has created a database, the Metathesaurus, that contains more than 140 classifications and terminologies. There is no evidence that physical therapists have created classifications or terminologies specific for the domain of physical therapy or in a systematic way evaluated classifications or terminologies that already exist for use in physical therapy. The author developed a valid and reliable terminology in Icelandic and English for treatments in physical therapy at Landspitali University Hospital and it has been implemented into the electronic patient record. Physical therapists need to systematically define what words or concepts are needed in classifications and terminologies so that they can represent the domain of physical therapy. Sjúkraþjálfun og skráning eiga sér langa sögu og til eru lýsingar af meðferðum sambærilegum þeim sem sjúkraþjálfarar nota í dag allt frá árinu 2600 fyrir Kristsburð. Löng hefð er fyrir skrifum sjúkraþjálfara í sjúkraskrá hér á landi bæði á pappír og á ...
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