Essential Tips for Proper Record Keeping

Health care professionals are expected to keep proper patient records relating to patient care and treatment. Good record keeping is crucial for professional accountability and compliance with the College’s Record Keeping Standard. Failure to maintain adequate charts according to the College’s Standard is considered professional misconduct. This applies to records in any medium, such as paper, electronic, audio, video, and photographs. 

Here are 10 essential tips for maintaining accurate and comprehensive records:

1. Make the time
Make time each day to document the patients seen that day while the information is fresh to improve the accuracy of your patient records. PTs may need to negotiate time with their employer for charting to maintain proper patient records.

2. Include all relevant patient information

Document conversations with patients that are relevant to treatment and care, rather than casual conversations. Document the nature of the conversation, what was discussed, any questions the patient asked, and how they were answered. It’s important to include dates of treatment or discussions with patients and ensure these details are accurate. For example, include who was involved, what care was provided, and when the care was given. 

3. Document patient consent in detail
Gaining and documenting consent is more than checking a box on a form. Include details from the conversation with the patient and document what the risks and benefits of treatment are, questions the patient asked, and the answers provided. Document whether the patient understood the discussion and agreed to proceed with treatment.

4. Keep records organized
All entries must be dated. If a PT thinks of something later or needs to enter a note into the patient record after the encounter, it can be marked as “late entry” and both the date of the item being recorded and the date the entry was made should be added.

5. Do not change the record
When making corrections or additions to patient records, the original content must remain readable. Corrections must be clearly shown as an alteration, complete with the date the change was made, along with the PT’s name and the reason for the addition or correction.

6.Use clear communication

Patients can request a copy of their record. Ensure you are using appropriate, respectful, and non-judgmental language. Records should state facts using clear, objective, and professional language. The use of shorthand may be acceptable but make sure that it’s easy to understand and include a reference sheet in the patient’s chart. 

7. Maintain records for the appropriate duration

Clinical and financial records must be retained for at least 10 years from the later of the following two dates: 

    • The date of the last patient encounter, or

    • The date that the patient reached or would have reached 18 years of age.

Ensure proper storage and accessibility of these records within this time frame. 

Utilizing standardized forms and templates for common documentation tasks such as initial assessments, treatment plans, and discharge summaries can help reduce charting time. These tools also help streamline the record keeping process. PTs must ensure they meet the expectations of the Record Keeping Standard.

9. Perform regular chart audits

Check audits are a useful way to foster ongoing quality improvement of a PT’s practice. Use the Record Keeping Checklist to review charts frequently throughout the year. 

10. Always include discharge summaries

Discharge summaries can include reassessment findings, reason for discharge and other recommendations. In the case of “no shows,” there should be a note in the patient’s chart that indicates the date of the nonattendance, the reason if known, and the patient’s status at the last appointment.

Proper record keeping is an essential aspect of physiotherapy practice. By following these tips, you can maintain complete, up to date, and well-organized records that are essential for high quality physiotherapy practice and continuity of patient care. After all, good record keeping enhances outcomes and the safety of patients. 

This blog was adapted from “Medical and Professional Recordkeeping and Documentation” by Sari Feferman, Rosen Sunshine LLP Jan 30, 2023