College Blog
Why is it important to keep good PT records?
Ask the six PTs who had mandatory reports sent to the College from their employers following their termination for failure to maintain adequate clinical records. Their unanimous response: that complete, up to date and well-organized records are essential for good physiotherapy practice, and continuity of patient care.
Each PT was directed to participate in record keeping training so that they could learn the record keeping requirements. Following their training sessions, the PTs agreed to share the lessons they learned.
Some PTs knew what the requirements were, and some did not. They all agreed that they often gave record keeping a low priority compared to direct clinical care. Notes were often poorly maintained, and sometimes not completed at all. Some records contained judgemental or non-patient centred comments, had late entries, or were missing relevant information.
Read this article to:
- Learn what these PTs wished they had known and applied to their practice.
- Understand your obligation to make and maintain adequate physiotherapy records.
Top tips from PTs:
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Top Tips |
Good practice |
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Make the time! |
Negotiate time with the employer to update your records. Factors like the PT’s experience, case load and the patient’s conditions will impact time required for record-keeping. Most of the PTs involved were new to practice and described needing at least an hour per day, sometimes divided into timeslots throughout the day, to maintain patient records. |
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Include all relevant information. |
Include who was involved, what care was provided and when the care was given. Reasons and justification for physiotherapy should be apparent as well as the outcomes from treatment. Standardized assessment and treatment template forms with editable fields could help reduce charting time. When working with these forms, initial each field to show that it has been reviewed, and make additions to the information as needed. Avoid leaving fields or checkboxes unanswered or blank – if a field is not applicable be sure to indicate that. One PT and employer explored voice recognition software to assist in record-keeping, reduce charting time and improve legibility. Many options are available. |
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Document patient consent for any proposed care. |
How much information should be discussed with the patient? Consider what the average, prudent patient needs to know in order to make an informed decision. PTs are responsible for describing the care, the risks and options to the patient or the substitute decision-maker. In general, the greater the potential risk associated with the proposed treatment, the more detailed the documentation should be. For example, if the treatment involves the patient undressing or is of a sensitive nature, the PT should document more information about the consent discussion, including any questions asked by the patient and the PT’s responses. |
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Record in the chart as soon as reasonably possible. |
Accuracy of the record improves if the chart is updated immediately after seeing the patient or while seeing the patient. A factor that may impact timelines is the acuity of the patient’s condition. For example, a patient with a respiratory condition may need their chart updated more than once per day, or immediately if preparing a patient for imminent discharge. Some of the PTs identified that if there were no notes there was question as to if the care was provided. |
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Do not change the record. |
If you realize later that some of the entry is factually inaccurate, add an addendum(addition to the record). Corrections must be clearly shown as an alteration, complete with the date the change was made, and the PT’s name. |
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All forms of communication regarding patient care must be documented in the health record. |
Use of telephone, email and text can enhance communication but you should also be aware of the risks – security, confidentiality, and managing expectations related to response time. Prior to communicating with a care provider or patient by text or email, consent should be obtained and documented in the health record and the PT should always include the date and time of the email or text, the message, significant information, and outcome. |
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Remember, patients have a right to access their PT records. |
State facts using clear and simple language. Consider what a patient will think when reading your notes. Do not include offensive or judgemental comments (e.g., terms like “alcoholic,” or sexist remarks, or comments that are not primarily patient centred comments). Only include things that are relevant to the patient’s care. |
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Discharge summaries are necessary even with “no shows.” |
If a patient does not attend for the last appointment, the note in their chart should indicate the date of the nonattendance, the reason if known, and should reflect the patient’s status at the last appointment. |
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Chart audits are a useful way to promote ongoing quality improvement. |
Use the Record Keeping Checklist to review a sample of charts frequently throughout the year. Keep a list of gaps and how they are addressed. Even better – ask a colleague who is included in the patient’s circle of care to do this. |
The following was taken from HIROC August 2017 (Strategies for Improving Documentation; Lessons from Medical Legal Claims):
In a case where there is inadequate or missing documentation, the courts will rely on the healthcare provider to testify as to their normal practice. Although this is an acceptable form of evidence, sole reliance on normal practice can significantly weaken the healthcare provider’s case and put their credibility as a witness into question.
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Awesome article. Thanks for it!