Patient Information

☐ Patient’s demographic information (at minimum, must have the patient’s full name, date of birth and contact information)

☐ At a minimum, one unique way to identify the patient (e.g., name and date of birth, unique patient number, etc.)

☐ The record clearly identifies who provided the physiotherapy care, by name and title, or by a unique identifier. 

Well Organized

☐ Each entry is dated.  

☐ Late entries include both the date of the item being recorded, the date the entry was made, and who made the entry.

☐ The date of every patient encounter, including missed appointments is recorded. 
If the person making the entry is different from the person providing care, they are also identified by name and job title, or by unique identifier.  

Understandable

☐ Entries are legible.

☐ Records are written in either English or French.

☐ If specialized terms, abbreviations, or diagrams are used, they must be understood by others who may be involved in the care (e.g., the abbreviations are commonly used in PT practice, are defined in the chart, or an abbreviation list is available to the reader.)

☐ Notations are respectful and non-judgmental.

Accurate

☐ Changes to the entries are dated and signed or initialled by the member.

☐ Original entry is visible or retrievable. 

Documentation of the therapeutic process

Clinical record includes:

☐ Patient’s health, family and social history.

☐ Patient’s reported subjective data.

☐ Record of the assessment(s) conducted

☐ Results of tests, investigations or measures

☐ Reports received about the patient’s care, if any

☐ An analysis of the collected data

☐ Clinical impression and physiotherapy diagnosis

☐ Patient goals.

☐ Treatment plan.

☐ Treatments performed.

☐ Details about any care that has been assigned to another person (e.g. which specific elements of the treatment plan were assigned to another person).

☐ Ongoing monitoring of the patient’s status and progression in meeting the goals

☐ Any updated information about the patient’s condition or relevant new information received is captured in the record
 
☐ Changes or modifications to the treatment plan.

☐ Discussions and communications with the patient including instructions, recommendations and advice

Discharge Summary

☐ Reassessment findings, if appropriate

☐ Reason for discharge.

☐ Recommendations and patient instructions 

Informed Consent

☐ Record of informed consent for assessment and treatment.

☐ Record of informed consent for involvement of other care providers.

☐ Care refusals.

☐ Relevant information about the substitute-decision maker, if applicable.

☐ Evidence the informed consent process is ongoing (e.g. when treatment has changed or diverged from the originally confirmed plan)

Involvement of Other Health Providers

Referral or consultation 

☐ Note about referrals and transfers to another health provider

☐ Reports about the patient’s care sent to another health provider, if any

Financial Records

Invoices/receipts include: 

☐ Name of the patient.

☐ Date of service.

☐ Name and title of the PT, PTA, and others who provided care under the PT’s supervision

☐ Description of the care, service or product provided.

☐ Amount of the fee for the care, service or product.

☐ Any payment received.

Privacy Requirements

Physiotherapists must comply with all legislation that protects the confidentiality of personal information and personal health information.

Here are some things physiotherapists must know related to privacy:

☐ I know who the Health Information Custodian is for my patient’s records.

☐ I understand my duties as either the Health Information Custodian or an agent of the Health Information Custodian (for example, by reviewing the College’s privacy resources).

☐ I have/follow policies and practices that protect patient confidentiality in the course of collecting, storing, using, transmitting and disposing of personal health information.

☐ My patients are aware of who has custody and control of their personal health information (i.e. who is the Health Information Custodian) and how their personal health information will be managed.

☐ I obtain explicit consent from patients before disclosing their personal health information to someone who is not a health provider involved in their care.

☐ I know how to respond to a request to access a patient’s health records (for example, by reviewing information from the Information and Privacy Commissioner).