Documentation Standard

Standard 

The physiotherapist maintains patient records that are accurate, legible, complete, and written in a timely manner. 

Expected outcome 

Patients can expect that their physiotherapy records are confidential, accurate, complete, and retrievable, and reflect the physiotherapy services provided.   

Performance expectations 

The physiotherapist: 

• Maintains legible, accurate, and complete patient records for all aspects of patient care in either French or English. 

• Completes documentation in a timely manner to promote patient safety and effective clinical care. 

• Confirms that the following information is retained as part of a complete patient record:  
  • Details of clinical care, and  
  • Financial records, in situations where fees for services or products have been charged. 

• Maintains patient confidentiality in the course of collecting, storing, using, transmitting and disposing of personal health information.  

Details of Clinical Care 

• Includes in the patient record detailed chronological information including: 
  • Unique patient identifier on each discrete part (each page) of the patient record. 
  • Whether the session was provided virtually. 
  • Patient’s reason for attendance. 
  • Patient’s relevant health, family, and social history. 
  • Date of each treatment session or professional interaction including declined, missed or cancelled appointments, telephone or electronic contact. 
  • Date of chart entry if different from date of treatment session or professional interaction. 
  • Assessment findings. 
  • Treatment plan, including parameters, and treatment goals. 
  • Documentation of informed consent and relevant details of the consent process reasonable for the clinical situation. 
  • Details of treatment provided and patient response to treatment, including results of reassessments, in sufficient detail to allow the patient to be managed by another physiotherapist. 
  • Details of tasks assigned to physiotherapist assistants. 
  • Details of relevant patient education, advice provided, and communication with or regarding the patient that is related to clinical care. 
  • Instances where the patient refuses care. 
  • Referrals and transfers of care to another health provider, and any reports sent regarding the patient’s care. 
  • Discharge summaries including reassessment findings, reason for discharge, and other recommendations. 
  • Documentation of any patient safety incidents, including near misses. 

• Ensures that the individual delivering physiotherapy services is clearly identified in all documentation.  

• When patient care follows a set care pathway or protocol, retains or ensures access to copies of those care pathways or protocols. 

Financial Records 

• Maintains accurate, complete, and retrievable financial records related to fees charged for the provision of any physiotherapy services and sales of products.  

• Financial records must include: 
  • Identification of the individuals involved in the delivery of the patient’s care, the name of the organization (for example, a physiotherapy clinic, corporation, hospital, or healthcare centre), the date of service, and the physiotherapy service or product provided. 
  • Patient’s unique identification. 
  • Whether the care being billed for was provided virtually. 
  • Fee for a physiotherapy service or product, including any interest charges or discounts provided. 
  • Method of payment, date payment was received, and identity of the payor. 
  • Any balance owing. 

Quality of Documentation 

• Confirms that documentation entered into the treatment record accurately reflects the assessment, treatment, advice, and patient encounter that occurred. 

• May reference rather than duplicate information collected by another regulated healthcare provider that the physiotherapist has verified as current and accurate. 

• Uses terms, abbreviations, acronyms, and diagrams which are defined or described to promote understanding for others who may access a patient’s record, and that a list of definitions is available and easily retrievable.  

• Clearly documents any changes, additions, or late entries made to the patient record, identifying who made the change and the date of the change, and ensures the original entry remains legible and retrievable¹. 

Record Retention 

Clinical and financial records must be retained for at least 10 years from the later of the following two dates: 

• Adult patients: the date of the last patient encounter, or 

• Patients who are children: the date that the patient reached or would have reached 18 years of age. 

It must be possible to retrieve and reproduce a complete clinical and financial record for each patient throughout the retention period².  

Electronic Medical Records 

• Knows that use of an EMR does not alter the physiotherapist’s obligations to ensure users are uniquely identified, entries and corrections are identified and traceable to a user, and data recovery/contingency plans are in place.

Footnotes

[1] If an Electronic Medical Record (EMR) system is equipped to track the name, date, and original content of changes or additions to a record, this information may be automatically captured in the audit trail. In this case, a separate notation does not need to be made.

[2] The requirement to retain patient records for a minimum of 10 years is set out in the Public Hospitals Act 1990, and this has been adopted by the College to apply to physiotherapists in all sectors. However, under the Limitations Act 2002, legal proceedings can be brought up to 15 years after any alleged act or omission. As a result, physiotherapists may wish to keep their records for longer than the minimum 10-year requirement.