The Case 

The College received a complaint from a patient who arrived at her regularly scheduled physiotherapy session and was surprised to find the clinic closed without notice – not even a note on the door. The patient attempted to contact the physiotherapist by phone and email, however her voicemail messages were not returned, and emails bounced back as undeliverable. 

Shortly after, the patient was contacted by the physiotherapist’s former assistant who told her that the PT had closed his office abruptly and his location was unknown. The patient then contacted the College for help getting a copy of her records. 

The College contacted the physiotherapist who confirmed that he closed the office but said he intended to move his clinic to a nearby city and all patient records were secure. He agreed to share his personal contact information with the patient so she could obtain her records. 

The patient contacted the PT a few times with no luck. Shortly after, the physiotherapist contacted the patient to ask which dates she visited the clinic. Approximately one month passed and still no records. The PT told the College that the files were physically located at the closed clinic and he was unable to retrieve them as he owed money to his landlord.  

However, about a week later, the patient received her records from the PT. The patient quickly contacted the College to indicate that the records were fabricated as all the information, including treatment dates and presenting symptoms, were inaccurate. The PT admitted that the records he provided to the patient were recreated. 

The physiotherapist continued to provide conflicting stories about the existence of patient records at the closed clinic and his access to them. As a result, the patient never received a copy of her records and over the course of the College’s investigation, more patients indicated that they were unable to contact the PT or access their patient records following the unexpected clinic closure. 

The Standards

The College’s Leaving a Practice Checklist details the professional obligations that physiotherapists have when going on temporary leave, retiring or leaving a clinic. Specifically, physiotherapists are responsible for ensuring there is a plan in place for patients who need ongoing care. 

Additionally, as the physiotherapist in this case was also serving as the Health Information Custodian, upon closing the facility he needed to ensure the secure storage of clinical and financial records for the minimum retention period – 10 years from the last patient encounter or 10 years after the patient reached, or would have reached 18 years of age. 

During this retention period, physiotherapists must be able to retrieve and reproduce a complete clinical and financial record for each patient. In this case, the patient attended physiotherapy for approximately five months and needed the patient record for insurance purposes, but the physiotherapist did not provide anything beyond fabricated records. 

The Record Keeping Standard clearly outlines that records must be accurate, that entries must be made within a reasonable time period and contain relevant information about a patient’s care in enough detail to allow another health care provider to assume care of the patient. 

The Outcome

The physiotherapist admitted to professional misconduct for discontinuing professional services that were necessary, failing to keep records in accordance with the standards of practice, falsifying records and failing to provide a record of treatment to the patient as requested.

The physiotherapist had his certificate of registration suspended for six months and will complete a one-year practice enhancement coaching program upon his return to practice. 

The outcome of this decision will be available on the Public Register permanently.
 
Record Keeping Standard
Leaving a Practice Checklist
Privacy