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Ms. Rase is a part-time Staff Physical Therapist, Home Health Department, Missoula Rehabilitation Center, Missoula Community Hospital, Missoula, MT 59801 (USA).
Ms. Tognetti-Stuffwas a part-time Staff Physical Therapist, Kodiak Hospital, and a substitute teacher, Kodiak School District, Kodiak, AK 99615, when this paper was written.
Adding an audit to the problem-oriented medical record system creates feedback to ensure quality control in the health-care field. Auditing is the process of comparing observed behaviors with predefined standards. The literature does not reveal an auditing system that has been tested for reliability. A standardized problem-oriented documentation system was developed at the University of Montana Physical Therapy Clinic. This system was then audited for assessment of its reliability. Kendall's coefficient of concordance (W) was used to determine interrater and intrarater reliability. We determined this documentation system to be reliable because our minimum coefficient of .80 was met. This reliable system aids in assessing objectively the care physical therapy students provide at the University of Montana.
Key Words: Medical records Physical therapy
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