The Case

The College was contacted by a third-party insurer following the review of a number of physiotherapy claims made by a member. After conducting their investigation, the insurer submitted a formal complaint to the College.

The physiotherapist was also the owner of a multi-disciplinary clinic that frequently treated patients following car accidents. Many treatments were covered, at least in part, by the patients’ insurance companies.

The insurer noted that many of the treatment records were nearly identical and that treatments would continue for months or years with no adjustments or notes about the patient’s progress.

They also found that in some cases, invoices were submitted on dates when the patient did not actually attend the clinic.

The College then reviewed an additional selection of charts from the PT that supported the insurer’s notes in the complaint. Further, the College found that many charts were missing key elements including record of assessment or reassessment by a physiotherapist, record of patient consent, or rationale for the continued course of treatment.

In some cases, there were no clinical notes at all, even though the patient or insurer was billed for treatment using the PT’s name and registration number. Some charts revealed that patients were receiving upwards of 150 or 200 treatments with only a handful, or even fewer, clinical notes.

The Standards

Clinical records are important communication tools that allow the physiotherapist and others to track the patient's past and current status, determine future care needs, give evidence of the care provided, collaborate when providing care, and transfer a patient’s care smoothly. In this case, many of the patient charts did not meet the requirements of the Record Keeping Standard and were missing critical elements including discussions about ongoing consent to treatment, objective measures and outcomes, and progress notes.

Additionally, the PT did not take reasonable steps to ensure that their name and registration number were used appropriately as outlined in the Fees, Billing and Accounts Standard — which states that physiotherapists must never create accounts that are inaccurate, false or misleading.

Further, a review of the patient charts highlighted that the PT was not acting in accordance with the Essential Competencies and Code of Ethics, as many charts were not individualistic and were missing justification for ongoing treatment.

The Outcome

The PT’s certificate of registration was suspended for a period of 15 months and they are required to successfully complete an ethics course and a comprehensive review of College standards.

They must also participate in a three-year practice enhancement coaching program with a focus on fees and billing, assessment and treatment, and record keeping. The suspension and terms, conditions and limitations appear on the Public Register.

The physiotherapist will pay all costs associated with the remediation and coaching programs in addition to $8,000 to the College.

Record Keeping Standard

Fees, Billing and Account Standard

Consent

Essential Competencies

Code of Ethics