How to Choose Patient Records for Practice Assessments

How to select patient records for your assessment:

• Choose five records that best reflect your current practice. Ideally, the records should be from the last year or two of your practice.
• Gather the entire physiotherapy record. A complete physiotherapy record can include the following:

• clinical notes (e.g., assessments, progress notes, reassessments, etc.)
• financial documents (e.g. copies of receipts for payment, if applicable),
• notes completed by the physiotherapist assistant (PTAs), including exercise tracking sheets
• attendance tracking sheets
• copies of exercise sheets (if any)
• forms signed by the patient
• reports sent to or received from others

• Include everything in the physiotherapy record. Don’t worry if the documents include notes created by other team members. The assessor is only reviewing your physiotherapy notes. You will not be evaluated based on entries created or edited by other team members, except in cases where you assigned and supervised the physiotherapy care to others (i.e. physiotherapist assistants)
• Select at least one record for each authorized activity (controlled act) you are on a roster to perform. For example, if you perform acupuncture and spinal manipulation, the assessor should review records that include these activities as part of patient care.
• If you work with physiotherapist assistants, submit at least one record where care has been assigned and supervised.
• Find at least one record representing a patient you discharged from treatment, if possible.