Clear Records Make a Difference  

The Case 

A patient complained that a physiotherapist prescribed an exercise that was too advanced, leading to pain and injury. They said the physiotherapist did not listen to their concerns that the exercise was too hard and did not obtain proper consent.  

The physiotherapist reported it was actually the patient who wanted the challenging exercise included in their treatment plan. The physiotherapist said they advised the patient of the risks and recommended a less challenging option instead. 

Because the patient and the physiotherapist had very different stories, the committee looked at the patient record to determine what happened.   

The patient record showed that:  

• The physiotherapist completed a comprehensive assessment, including subjective and objective testing.  

• The physiotherapist prescribed progressively harder exercises as the patient progressed. 

• When the patient tried the challenging exercise during an appointment, they struggled, and the physiotherapist advised it was likely too hard at this point in their recovery.  

• The physiotherapist provided a less difficult option and informed the patient of the risks of continuing with the challenging exercise.  

• Ongoing consent to assessment and treatment were documented throughout.  

The Standards 

The Documentation Standard requires physiotherapists to maintain records that are accurate, complete, and written in a timely manner. The patient record should be detailed enough that another physiotherapist could take over care and have all the relevant information. 

Examples of things physiotherapists must document include: 

• Assessment findings 

• The treatment plan, including parameters and treatment goals 

• Details of treatment provided and the patient’s response 

• Relevant patient education, advice provided and communication related to care 

• Informed consent and key details of consent conversations 

See the Documentation Standard for a full list of what information needs to be included in the patient record.  

Good documentation protects the physiotherapist and the patient.  

When it comes to consent, physiotherapists must: 

• Ensure the patient understands what they’re consenting to. This includes explaining the nature, risks, benefits and side effects of a treatment, along with alternative options. 

• Document conversations about consent on an ongoing basis.  

See the College’s Consent Resource for full details.  

The Outcome 

 In this case, the physiotherapist met the requirements of the Documentation Standard and consent legislation, and the patient record supported their version of events.  

The committee decided to take no action.  

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