Case of the Month
The Case
The College received a complaint from a patient who was unhappy with the care they received at a physiotherapy clinic.
The patient started going to physiotherapy after they were hurt in a car accident. Despite regularly attending appointments at the clinic for around two months, the patient said they rarely saw their physiotherapist. Instead, most of the treatments were provided by a physiotherapist assistant (PTA). The patient didn’t like the physiotherapist assistant and didn’t think the treatments were effective.
When contacted by the College, the physiotherapist said although a PTA had provided some care to the patient, the physiotherapist themselves had performed all assessments and reassessments.
However, the clinical record showed otherwise.
The Standards
As a physiotherapist, when you assign care to a physiotherapist assistant, you remain responsible for that care. See the Working with Physiotherapist Assistants Standard for more details.
It’s important to note that some care cannot be assigned, including assessments and reassessments.
Assessments and reassessments must be performed by a physiotherapist, so they can determine the appropriate treatment plan. A physiotherapist assistant can help provide the care outlined in that treatment plan, but they should never be the one creating or re-evaluating the plan.
In this case, the patient’s clinical record showed that a physiotherapist assistant had reassessed the patient. This is not allowed under the Working with Physiotherapist Assistants Standard.
Important conversations about consent were also missing from the patient record. The patient signed a consent form during their first appointment at the clinic, but ongoing consent to treatment was not documented in the patient record.
Importantly, physiotherapists must get a patient’s consent to involve others, such as physiotherapist assistants, students and volunteers, in their care. This requires a conversation with the patient about the roles and responsibilities of the physiotherapist and the physiotherapist assistant, student or volunteer.
In this case, there was no evidence that the physiotherapist had obtained the patient’s consent to involve a physiotherapist assistant in their care.
The Outcome
The committee decided the concerns raised by this case were severe enough to require the physiotherapist to work with a practice enhancement coach for one year. The physiotherapist was also required to review College resources on record keeping, consent and working with physiotherapist assistants.
Learn More
Record Keeping Checklist
Are you interested in improving your record keeping? Consider downloading the Record Keeping Checklist to review your notes and ensure you are meeting standards and requirements.
Consent Resources
Review College resources on consent.
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