The importance of teaching the discipline "medical documentation in rehabilitation institutions" in the training of specialists in physical therapy

Abstract

Proper maintenance of medical records is an important component of the activities of all health care institutions. The recently adopted law on rehabilitation in the field of healthcare introduces the functioning of a modern system of rehabilitation in the field of healthcare, that is, the provision of high-quality rehabilitation care directly in healthcare institutions from the very beginning of the disease or injury. Taking into account the modern paradigm of healthcare and physical therapy with their focus on human functioning, activity and participation, the International Classification of Functioning, Disability and Health (ICF) should be used in the formation of a rehabilitation diagnosis. From the definition of the rehabilitation diagnosis, which is encoded by the ICF categories and which contains the goal of rehabilitation in general and the objectives of the rehabilitation program, the individualization of physical therapy for each patient begins. That is, the rehabilitation system is based on a biopsychosocial model of limiting daily functioning/vital activity, a rehabilitation strategy for healthcare and ICF.