Clinical Documentation During Clinical Placements: Perspectives of Physiotherapy Students and Clinical Educators

Abstract

Background : Clinical documentation is a critical form of communication in healthcare settings. As defined by the Physiotherapy Practice Thresholds, clinical documentation that complies with relevant professional and legal obligations is a requirement for all physiotherapists in Australia and New Zealand. Aims : The aims of this study were to explore the experiences of clinical documentation and perceived support and training needs for physiotherapy students whilst on clinical placement, from the perspective of students and clinical educators. Method : A qualitative approach was used to investigate physiotherapy student (n=18) and clinical educator (n=17) experiences and perspectives. Interviews from eight focus groups were professionally transcribed, and reflexive thematic analysis was applied to the data to determine common themes. Results : Four overarching themes were generated; 1) Recognising the value of documentation, 2) Variance of expectations, 3) Challenges in measuring performance, and 4) Clinical placement readiness and requirements. Conclusion : The main findings from this study identify the unique challenges that students experience to meet documentation requirements on clinical placement. This study highlights the shared responsibility of university education providers and clinical placement facilities to support students to understand the importance of clinical documentation and assist in improving their documentation skills.