Patient Waited Almost Two Months for Records

The Case 

The College received a complaint from a patient who had waited more than six weeks to receive their clinical records from a physiotherapist – well beyond the 30 days required by law.  

The patient needed the records to submit a benefit claim to their insurer. On September 2, they contacted their physiotherapist to request the documents. Despite calling, emailing and even visiting the clinic multiple times over the next month and a half, they still hadn’t received the records by October 21 when they reached out to the College for help.  

Over this time, the physiotherapist gave the patient various reasons for not providing the records. These included saying they needed to transfer notes that were written on scrap paper into the official patient record first and they were backed up with several other record requests.  

With the patient’s permission, the College contacted the physiotherapist to ask about the delay. The College emphasized the patient had waited around 50 days and the physiotherapist had a legal obligation to provide the records in a timely manner. 

The physiotherapist gave the patient a copy of their records three days later.  

The Rules  

Patients have a right to access their personal health information.  

In most cases, the Personal Health Information Protection Act (PHIPA) requires physiotherapists give patients a copy of their records within 30 days of receiving an official request. 

Delays in providing this information can harm patients, particularly when the records are needed for insurance benefits or medical referrals.  

The physiotherapist’s practice of writing treatment notes on pieces of scrap paper and then transferring them into the official patient record later was also concerning.  

Legally, treatment notes are considered personal health information and are subject to the same protections under provincial privacy law. Physiotherapists must ensure this information is appropriately safeguarded. 

When an investigator reviewed the patient record in this case, they found that several entries were missing dates to indicate when the information was added.  

According to the Record Keeping Standard, physiotherapists must enter information into patient records within a reasonable timeframe. This ensures information is captured accurately. 

All entries in a patient record must be dated. Late entries must include both the date of the item being recorded and the date the entry was made. 

The Outcome 

The physiotherapist said they had made several changes to their practice in response to the complaint. These included introducing mandatory annual record keeping training for all employees and creating a detailed policy for handling requests for medical records.  

In reaching their decision, the committee considered the physiotherapist had no previous history of complaints and had made improvements to their practice to prevent similar situations. The committee decided to recommend the physiotherapist review College resources on record keeping and privacy, along with the associated legislation.  

All dates and identifying information have been changed 

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