The Case

The College received a complaint from a hospital health care team about the treatment of a patient who was admitted to the hospital for a variety of health challenges. At the time of admission, the patient was non-verbal, experiencing neurological deficits and had limited brain function.

The complaint was about a physiotherapist who had worked with the patient for many years prior to their admittance to the hospital. Once the patient was admitted they were treated exclusively by the hospital PT. However, after a few months the patient’s family scheduled private physiotherapy sessions with their long-standing physiotherapist, in addition to the services provided by the hospital.   

The long-standing PT conducted an assessment during the first private appointment in hospital and continued to treat the patient regularly, with the support of their own physiotherapy assistant, until the hospital chose to end the external health provider agreement.

The complainant indicated that the long-standing PT did not provide the hospital team with a plan of care or patient goals and did not include the assessment report in the patient’s hospital file. Instead, the PT provided it to the patient’s family directly. Additionally, the hospital PT found that the clinical notes were vague and difficult to follow.

Following a meeting between the hospital care team and the PT, the hospital team became concerned that PT’s goals for the patient were unreasonable and not aligned with the goals established by the hospital PT. They worried that the long-standing PT’s goals were giving false hope to the patient’s family.

The PT stood by the assessment findings and patient goals, disputed that the clinical notes were infrequent or vague, and indicated that the hospital’s expectations were not clear.

The Standards

The Collaborative Care Standard states that the PT must collaborate with the patient and others involved in the patient’s care (including family members and other service providers) when it’s relevant to the physiotherapy plan of care. The collaboration should ensure that the plan of care addresses the needs and goals of the patient. A physiotherapist must recognize problems or conflicts that arise in a collaborative care setting and take reasonable steps to resolve them.

Physiotherapists must ensure that patient records are organized, understandable and accurate in accordance with the Record Keeping Standard. Entries should include enough detail to allow another health care provider to assume care of the patient or follow the plan of care.

The Outcome

The Committee identified concerns about the PT’s ability to work collaboratively with a broader health care team and their record keeping practices.

The physiotherapist was provided with advice and recommendations regarding practice, encouraged to review the Collaborative Care and Record Keeping Standards, and asked to complete the College’s Record Keeping E-Learning Module.

Collaborative Care Standard

Record Keeping Standard

Record Keeping E-Learning Module