The Case
The College received a complaint from a patient who received physiotherapy treatment for their shoulder. The physiotherapist conducted an assessment, established a diagnosis, and created a treatment plan that involved exercises and modalities. The patient attended physiotherapy twice a week and was also given exercises to do at home.
During one of the sessions, the patient mentioned that they noticed increased shoulder pain while doing day to day activities. The physiotherapist spoke with the patient about their condition and suggested that the patient modify their activities to help manage the pain. At the end of the appointment, the physiotherapist applied physiotherapy tape to the patient’s left shoulder. The PT recommended that the patient leave the tape on for a few days.
The patient arrived at their next appointment with a bandage on their left shoulder. The patient said the physiotherapy tape was itchy, and ultimately caused a large, open blister on their shoulder. The patient felt like the PT was not sympathetic and did not offer them an apology for the tape causing an injury. The patient said they were unaware of any potential risks of using physiotherapy tape, and the PT never told the patient to remove the tape early if they were uncomfortable.
The physiotherapist noted that they made an effort to avoid touching the patient’s shoulder area during treatment and helped the patient re-bandage their shoulder. The PT also mentioned consulting with their colleagues about the patient’s adverse reaction to the tape. The patient did not return to physiotherapy after the incident.
The Standards
According to the Record Keeping Standard, physiotherapists must keep thorough patient records. Records allow PTs to track a patient’s medical history, assess their present condition, determine future care needs, and provide documentation of the care provided. Records are equally important to help support what a physiotherapist did or did not do.
In this case, several key details were missing from the record. For example, the PT did not document the use of the physiotherapy tape and there was no mention of the blister on the patient’s shoulder, or the steps that the PT took to address the adverse outcome.
Further, the patient record did not include any evidence that the patient consented to certain aspects of treatment, including the use of physiotherapy tape. Obtaining consent must include a discussion about the nature of the treatment, benefits, risks, side effects, the alternative courses of action, and any possible consequences of not having the treatment. According to the patient, they were unaware of the risks associated with physiotherapy tape, and there was no evidence in the patient record to dispute this claim.
The Outcome
The Committee decided to provide formal advice to the physiotherapist about record keeping. The PT was advised to document the patient consent process, including explaining the risks and benefits of treatment as well as alternatives to the proposed plan. They were also reminded to document the use of any treatment modalities, including the area being treated, any adverse event that may have occurred, and steps that the PT took to mitigate the issue.
Record Keeping Standard
Consent Resource