The Situation

The College was contacted by the Ministry of Health and Long-Term Care about a physiotherapist with whom they had concerns. These concerns centred on record keeping, assessment and treatment practices. Based on a Ministry review of 21 patient records, they felt the PT in question was not practicing to standard and asked the College to explore it.

Important to note, this was not the first time the physiotherapist’s name had come to the College’s attention. Just a year before, the College had received a Ministry report expressing similar concerns about the same physiotherapist.

At the time of the first complaint, the Inquiries, Complaints and Reports Committee launched an investigation and identified several issues with this individual’s record keeping.

In the spirit of remediation, the Committee advised the physiotherapist to review the College’s record keeping resources, with the expectation that this would be an opportunity to learn and improve.

However, with a second complaint in front of them, the Committee was compelled to take a hard look at the PT and evaluate both historic and recent patient records to determine where the problems lay.

The physiotherapist was asked to, and complied, by providing three patients records covering different time periods.

It is a physiotherapist’s responsibility to ensure that patient records include all relevant information in sufficient detail. By ensuring that patient records are comprehensive and complete, physiotherapists provide the ability to track a patient’s course, determine future care needs and give evidence of and rationale for the care provided.

Consequences

The Committee was disappointed that despite the physiotherapist having already had a complaint and having previously been asked to review the College’s record keeping resources, serious record keeping practice issues persisted.

The records lacked sufficient detail, and did not include objective measures in the initial assessment and discharge notes. 

Because the physiotherapist had not made the necessary practice changes as a result of the earlier complaint, the Committee ordered more specific interventions. The physiotherapist was required to participate in a Specified Continuing Education and Remediation Program (SCERP), for three years.

Under the terms of the SCERP, the physio had to complete reviews of the Record Keeping Standard and Guide, and the Record Keeping checklist. She was also required to review the Record Keeping Video within 30 days.

Following these reviews, a coach approved by the College will meet with the physio and review randomly selected records. The reviews will continue until the records are satisfactory – there could be as few as two or as many as twelve meetings over the three-year SCERP.

The physiotherapist must pay all costs associated with the coach’s visits.

The SCERP also becomes part of the physiotherapist’s public record on the Public Register for a minimum of three years.