According to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, any information in the medical record that contains “protected health information (PHI)” should be kept confidential, and all health care providers should safeguard the availability and integrity of health care information in oral, written, or electronic forms.⁶ PHI includes any information that pertains to the past, present, or future physical or mental health conditions of an individual, including provision of care, payment of care, and demographics.⁷ A subset of the Privacy Rule is the Security Rule, which specifically addresses the confidentiality of electronic PHI (e-PHI). The Security Rule states that a covered entity must ensure the integrity and availability of e-PHI that it creates, maintains, or transmits.⁸ The goal of the Security Rule is to protect e-PHI as institutions such as hospitals adopt new and efficient technologies.⁸ Specific topics, such as human immunodeficiency virus status, substance abuse, domestic abuse, or psychiatric history, are privileged information, and discussion of them is subject to additional ethical and regulatory guidelines.⁹

The physical therapist must be compliant with HIPAA,¹⁰ the American Physical Therapy Association’s Guide for Professional Conduct and Code of Ethics for Physical Therapists,^11,11a and any policies and procedures of the facility or state in regard to sharing medical record information with the patient, family, caretakers, visitors, or third parties.

Clinical Tip

To ensure confidentiality of PHI in the acute care setting, the physical therapist should log off the computer when not in use, keep the written medical chart and flow books closed when not in use, cover any paperwork kept on clipboards when traveling in the facility, and use discretion when discussing patient information in shared rooms, hallways, and/or elevators.

Physical Therapist Documentation

The physical therapist should comply with the documentation standards including, but not limited to, the policies/procedures of the organization, the state, and the American Physical Therapy Association’s Guidelines for Physical Therapy Documentation of Patient/Client Management.¹²

In general, documentation must be:

• Dated and timed with an authenticated signature, including therapist credentials

• Legible and in black ink (in a paper chart)

• Clearly labeled with the appropriate patient identification

• Complete, accurate, and objective

• Cosigned for a physical therapist assistant or student therapist

Documentation should be free of ambiguous acronyms or abbreviations to minimize misinterpretation and prevent errors that could result in patient safety issues (Table 2-1).¹³

TABLE 2-1

Prohibitive Abbreviations *

Do Not Use	Potential Problem	Use Instead
U, u (unit)	Mistaken for “0” (zero), the number”4” (four) or “cc”	Write “unit”
IU (International Unit)	Mistaken for IV (intravenous) or the number 10 (ten)	Write “International Unit”
Q.D, QD, q.d., qd (daily) QOD., QOD, q.o.d., qod (every other day)	Mistaken for each other Period after Q mistaken for “I” and the “O” mistaken for the “I”	Write “daily” Write “every other day”
Trailing zero (X.0 mg)† Lack of trailing zero (.X mg)	Decimal point is missed	Write X mg Write 0.X mg
MS MSO₄ and MgSO₄	Can mean morphine sulfate or magnesium sulfate Confused for one another	Write “morphine sulfate” Write “magnesium sulfate”