Case of the Month
The Case
The College received a report from a manager at a health care company that provided in-home care, including physiotherapy, to older adult patients.
The report raised concerns about the record keeping practices of a physiotherapist who was employed by the company for approximately five years. After being made aware of the concerns about their practice, the PT resigned. The employer noted the following concerns about the PT’s record keeping:
- Assessments were lacking detail.
- Goals were not measurable, making it difficult to track progress.
- Prescribed exercises were not always linked to the patient’s diagnosis.
- Late entries in the clinical records were not dated.
As part of the investigation, the College reviewed 12 patient records and noted the same issues raised by the employer.
The employer also expressed concerns about the PT’s ability to meet the requirement to return patient records to the company (the Health Information Custodian) following their resignation. It took a couple of weeks for the PT to return clinical records for patients who were discharged several weeks prior. The employer felt that the delay in returning the patient records was unnecessary as the records should have been up to date at the time of discharge.
In their response to the College, the PT indicated that the treatment plans appeared repetitive because most of their patients had the same rehabilitation goals even though their medical diagnoses were different. The PT also noted that they did not diagnose patients after the physiotherapy assessment as the patient files often already contained a medical diagnosis.
Regarding returning the patient files to their employer, the PT mentioned wanting additional time to organize the files before returning them to ensure the administrative details were complete, the paper files matched the electronic version, and that the billing records were audited.
The Standards
Record keeping is a key component of patient-centred care. The main purpose of record keeping is to capture information relevant to the patient’s care for the benefit of the patient and future caregivers. Clinical records provide the ability to track a patient’s course, determine future care needs and give evidence of and rationale for the care provided. Records also serve as an important communication tool that allows others to understand the patient’s past and current status.
The College’s Record Keeping Standard requires physiotherapists to include:
- Details about analysis, diagnosis, patient goals, treatment plan, and treatments performed.
- Progress notes, outcomes, reassessments, and resulting changes to the treatment plan.
- Discharge summaries including reassessment findings, reason for discharge and other recommendations.
Many of the PT’s clinical records did not meet these requirements.
Physiotherapists must also follow the rules of the rules of the Personal Health Information Protection Act (PHIPA) which prohibits the unauthorized use or collection of personal health information. In this case, the PT was not the HIC or a designated agent of the HIC but still retained records that did not rightfully belong in their possession for a couple of weeks.
The Outcome
The College was concerned that the PT’s clinical records did not meet the requirements of the Record Keeping Standard. The College was also concerned with the PT’s inability to return patient records to the HIC in a timely manner.
To help address these concerns, the PT will be required to complete a Specified Continuing Education or Remediation Program (SCERP). The SCERP will include reviewing several College resources, completing a training course and working with a practice enhancement coach. All costs associated with the SCERP will be paid by the physiotherapist.
As a PT and healthcare provider, it is paramount that we take proper notes and document what is necessary. In the case that this does not happen, it may lead to improper care for the patient as well as makes it difficult for another PT to continue care
I feel documentation is one of the important task in the practice. It is important to document patient’s notes accurately with measurable goals so then if another provider ever needs to refer the notes, they can follow the plan of care for the patient.
To my understanding something you didn’t document means you didn’t perform or do . Hence, it is necessary to document in timely manner.
Record keeping is an essential aspect not just for one as a professional but also to ensure a smooth continuum of care and collaboration between all those involved in a said person’s care.
To maintain notes is very important to access the patients details, and it has be clean and clear to read for other clinicians too.
Accurate , clear, timely and detailed clinical records are very important, for both patient and health care providers, to ensure proper care. Sound clinical recors becomes very important to ensure smooth transition of care, in case like this where care provider was changed . Overall good treatment is never complete without good clinical record keeping.
Record keeping is an essential task in delivering an efficient treatment to patients.
While sometimes take time to have complete clinical record but it helps PT to have better understanding of patient situations and needs and also help PT to have reasonable answers to potential question about patients record.
One of the main key components of being PT is documentation with required standards, time management, proper organization, scheduling and proper data stipulation.
PTs all understand the importance of documentation and record keeping but we need to remember to be detailed, clear and complete to ensure best outcomes for our patients.