Documentation and Record Keeping Standard of Practice PDF
Standard
The physiotherapist maintains documents/records that are accurate, legible and complete, written in a timely manner, and in compliance with applicable legislation and regulatory requirements.
Expected outcome
Clients can expect that their physiotherapy records are confidential, accurate, complete, and comply with applicable legislation and regulatory requirements.
Performance expectations
The physiotherapist:
- Maintains and shares all documentation, correspondence, and records (e.g., paper, electronic) in compliance with applicable legislation and regulatory requirements including confidentiality and privacy standards.
- Maintains legible, accurate, complete (e.g., date, provider signature, unique client identification), and timely records related to all aspects of client care in either French or English.
- Includes in the chart record detailed chronological information regarding the:
- Client’s identity (name, birth date, unique identifier) on each discrete part (each page) of the client record.
- Client’s reason for attendance.
- Client’s relevant health, family, and social history.
- Dates of each treatment session or professional interaction, including missed or cancelled appointments, telephone or electronic contact.
- Assessment findings.
- Treatment plan and goals.
- Details of treatment provided and patient response to treatment, including results of reassessments.
- Details of all client education, advice provided and communication with or regarding the patient.
- Includes sufficient detail in the record to allow the client to be managed by another physiotherapist.
- May reference rather than duplicate information collected by another regulated health-care provider that the physiotherapist has verified as current and accurate.
- Minimizes the use of abbreviations and acronyms, and writes out the full word or phrase followed by the abbreviation in parenthesis the first time it is used.
- Employs tracking and documentation mechanisms so that the personnel providing client care or other services can be identified (e.g., when care is provided by a physiotherapist assistant).
- Confirms that all correspondence (e.g., electronic communication, social media) and documentation is professionally written in compliance with applicable legislation and regulatory requirements.
- Secures all personal information contained in paper or electronic records (while in use, storage or during transfer) through the appropriate use of physical, technical and electronic security mechanisms (e.g., passwords, encryption, locked offices/file cabinets) to protect the privacy of patient information.
- Verifies that all electronic records incorporate an audit trail that clearly captures access and that both electronic and paper records have an audit trail that clearly captures documentation or alterations made to the record clearly identifying:
- Who made the change or addition.
- Date the change was made.
- Makes a reasonable effort to confirm that all professional electronic correspondence is sent to the intended recipient.
- Retains, or ensures ongoing access to copies of care pathways or protocols in addition to patient records in circumstances where patient care delivery and documentation is according to a protocol, or where charting by exception is employed.
- Maintains complete and accurate financial records for every circumstance in which he/she provides treatment, renders any service, sells or provides a product. Financial records must include:
- Identification of the service provider and organization, date of service, and product or service provided.
- Client’s unique identification.
- Fee for product or service, including any interest charges or discounts provided.
- Date payment was received and identity of the payer.
- Any balance owing.
- Retains records (e.g., client, financial) according to the length of time specified by applicable legislation and regulatory requirements.
- Clinical and financial records are retained for ten (10) years after the last date of service.
- Clinical and financial records for minors are retained for ten (10) years past the minor’s 18th birthday.
- Retains records in a manner that enables a complete or any component of the record to be retrieved and copied upon request, regardless of the media (paper or electronic) used to create the record.
- Disposes of records (e.g., electronic, paper) in a manner that maintains privacy and confidentiality of personal information.
- Takes action to prevent abandonment of client records (e.g., in the case of retirement, closing a practice).
- Is aware and informs employers, support personnel, and others of their professional obligations regarding record keeping and management.
- Provides a copy of the complete clinical and financial record to the client or their authorized representative upon request and appropriate consent.
- Verifies and documents that equipment used in physiotherapy practice is routinely inspected, maintained, and calibrated on a regular basis according to applicable legislation and manufacturer’s recommendations and retains equipment records for five (5) years.
