The Case
The College received a complaint from a patient who attended physiotherapy after falling at work. The patient was referred to a clinic through the Workplace Safety and Insurance Board (WSIB) and completed a right hip assessment with various health professionals including the physiotherapist. The patient arrived at the assessment using a cane for support.
The patient continued to attend physiotherapy for several weeks until it was advised by the physiotherapist that they could return to work with modified duties, pending WSIB approval. However, the patient was worried that the discharge report did not mention the need for a cane for mobility, which the patient believed was important for their return to work. According to the patient, this led to the denial of specific funding by the WSIB, and ultimately impacted their ability to return to work. The patient also believed that a handwritten note outlining their need for a cane was included in the patient record.
When the patient phoned the physiotherapist to discuss the discharge report and explain their concerns, the patient felt like the PT was dismissive and unprofessional by refusing to change the report and abruptly ending the call.
During the phone conversation, the PT explained that while the discharge report noted the patient's preference to use a cane, it didn’t mean that the physiotherapist thought it was medically necessary. The physiotherapist also noted that the care team could conduct a reassessment if approved under WSIB.
The PT said the patient was insistent that the report was changed to include a medically required cane under WSIB funding. The physiotherapist was not willing to change the report, and decided to end the call as the conversation was no longer productive.
The Standards
In reviewing the patient record, it appeared that the PT conducted a comprehensive assessment, established a diagnosis, and developed a patient-centred treatment plan with the rest of the healthcare team.
The patient was concerned that a cane was not included as a requirement in their discharge plans, however there was no documentation to show that a cane was clinically indicated. The patient mentioned a handwritten note supporting their cane requirement, but it was unclear who this note was from, and it couldn’t be found in the patient file.
The Record Keeping Standard specifies that physiotherapists must maintain all clinical records about their patient to track the patient’s past and status, determine future care needs, and collaborate when providing care. Had this note been provided by the patient or drafted by the PT, it would be the Committee’s expectation that it was included in the record. Physiotherapists should be sure to include any important clinical information in the patient record, no matter how formal or informal it is.
The Record Keeping Standard also states that all entries must be permanent and accessible. If there are additions or corrections, the original content must remain. Although the patient asked the physiotherapist to change their recommendations to the WSIB, such a change would only be appropriate if it was clinically indicated. The PT made the right choice by not changing the patient’s record without conducting a new assessment.
The Communication Skills resource outlines the importance of clear, professional and empathetic communication. Physiotherapists should always be mindful of their communication, particularly when working with patients who are experiencing difficult circumstances, like not working for an extended period because of an injury.
The Outcome
The Committee decided to take no action regarding the assessment, diagnosis or treatment provided by the physiotherapist. However, the Committee believed there could be some improvements in the PT’s approach to patient-centred communication.
Although no formal action was taken, the physiotherapist was advised to reflect on their patient communication skills to make sure they always communicate with patients in a sensitive way, and to take extra care to ensure any relevant clinical information was included in the patient record.
Record Keeping Standard
Communication Skills Resource
Essential Competency Profile for Physiotherapists