The Situation

Who should the College believe: an unhappy patient or a PT?

Experienced physiotherapist, Thomas Bow remembered it so clearly. According to the PT, he explained his treatment plan, the costs and the associated risks clearly to the patient. He even wheeled in the skeleton to explain the shoulder joint and its intricacies to the patient and her husband. 

And his notes show that … he ticked the consent box. Nothing more. No notes describing the conversation or the potential risks and nothing at all on her expressing that she understood the plan. 

The patient and her husband remember it clearly as well, if very differently. According to them, Mr. Bow didn’t discuss the proposed treatment, the risk factors, the time or the cost of the treatment plan. Unfortunately, during the course of the treatment, the patient became increasingly frustrated.  

She was concerned about her lack of progress. She said that during her treatment, when Mr. Bow put his hands on her pectoral muscles and her pelvic area, she didn't understand why. 

She felt his treatment was too aggressive and resulted in doing more harm than good, especially a back exercise that required rotation and left her feeling worse, not better. She complained about his skills as a physiotherapist, as well as his failure to get informed consent.

The Inquiries, Complaints and Reports Committee of the College was left with two questions to answer:

• Was Mr. Bow’s clinical plan based on sound professional judgement and was it indicated by the injury he was presented with? 
• Did Mr. Bow get true informed consent from the patient? 

What Happened Next

The College contacted Mr. Bow and he responded to the complaint, detailing his treatment plan and submitting his records. With respect to the issue of consent, the records included a ticked consent box, but no description and therefore, the notes failed to capture any details about the conversation. 

And that ticked box without notes is worth next to nothing when a complaint comes to the College. 

Regarding the clinical concerns put forward, the Committee sought an independent peer review of Mr. Bow’s treatment plan as part of their investigation.  The peer supported Mr. Bow and said that the exercises he prescribed to the patient were commonly used to increase mobility in shoulder injuries. 

The Committee observed, based on this information, that his clinical judgement seemed to be sound, but his notes about his instruction about the exercises the patient was supposed to use were lacking. 

The Consequences

The panel of the Inquiries, Complaints and Reports Committee felt that the problem with the records did not warrant heavy handed intervention (they observed that it was the first complaint they had received about Mr. Bow) but they did think that there was room for improvement in his practice and were concerned that the gaps in his records could lead to bigger problems if they continued.  

They offered Mr. Bow strong advice that he must not only discuss his proposed treatment with patients and get informed consent to proceed, but he must also clearly document this conversation in the patient file. 

They told him that for consent to be truly informed, the patient must have a clear understanding of what he or she is consenting to have done. The panel referred Mr. Bow to the College’s Record Keeping Standard Checklist to help him avoid a situation like this in the future. 

Taking the time to demonstrate and capture that you – and your patient – have had a conversation and understand the plan not only ensures informed consent but can avoid a disagreement down the road.  

Health Care Consent Act
Video: Did You Get Consent?
Read the Standard: Record Keeping
Record Keeping Checklist