Key Takeaways
- You must document all communications with or regarding a client regarding their physiotherapy care.
- Emails, phone calls, and text messages are all considered forms of communication to be included in the client record.
- Phone calls should be summarized providing a brief description of the main points and entered directly into the client’s chart.
- Texts can be documented as a screen shot or summarized.
Physiotherapy is not only the assessment completed and the treatment provided to a client. It is also the communication that occurs before, during, and after those interactions. Physiotherapy includes the education provided to the client regarding their injury, the advice given about how to manage it, what to expect after treatment, and what to watch out for that would suggest an adverse reaction to treatment. It is important to understand that you must document not only the assessments and treatments provided, but also the communication that contributes to the complete picture of what occurred during physiotherapy.
Communication with clients and others involved in the client’s care can occur in person during the treatment session or via email, phone, or text. It is important to document all these interactions as part of the client’s chart record as documentation provides both the physiotherapist and the client with a testament of what actually occurred during care. This article will discuss what communications need to be documented, and the rationale for documentation requirements. Several common scenarios related to documenting client communication are also highlighted.
What communications do you need to document?
Components of a Complete Client Record
- Confirms that the following information is retained as part of a complete client record
- Details or copies of all incoming or outgoing verbal or written communication with or regarding the client
- Details of all client education, advice provided, and communication with or regarding the client
- Date of each treatment session or professional interaction including declined, missed or cancelled appointments, telephone or electronic contact
Communication with the client and others involved in their care is a key part of physiotherapy services. Communication related to client care completed via emails, texts, phone conversations, etc. must all be documented. This includes all discussion around client care such as education, advice, alterations to the treatment plan, identifying barriers, as well as scheduling changes such as missed or cancelled appointments. Communication around financial matters such as denial or approval of funding can directly impact care and should also be documented.
Why is this documentation required?
The College’s mandate is to protect the public interest. The Standards of Practice establish that you must document client communication as doing so enables the physiotherapist to provide safe, quality, and effective care.
Documentation of the details of client care ensures that any physiotherapist or other health provider involved in the client’s care is aware of your assessment findings, treatment plan, and any education you have provided. Documenting communication provides important details of care such as education, advice, updates on treatment plans, etc. Failure to document these communications can have significant consequences for the client.
At all levels of health care, miscommunication can erode trust and the therapeutic relationship. Miscommunications can lead not only to a breakdown in trust and the therapeutic relationship but also safety issues. If you fail to document a client conversation that involves a red flag or contraindication or if the client misunderstands your instructions and does something that results in an adverse event it can result in serious consequences for the client and potentially you.
Documentation is reviewed in the event of a chart audit, a complaint, or a civil proceeding and is examined to determine what did and did not occur. Failure to properly document your care as well as your communication can put you in a serious situation.
The medium in which it was communicated
Whether communication is through email, text, or a phone call doesn’t matter. It must be recorded in the client record.
Text and email can be uploaded directly into most EMRs. One of the identified risks of email and text communications is that these forms of communication can lead to exchanges that are informal, unprofessional, or otherwise inappropriate for the therapeutic relationship. One of the performance expectations specified in the Communication Standard is that the physiotherapist “Confirms that any exchanges using electronic communications are appropriate for therapeutic relationships established with clients.” Although not required, uploading these message types directly into an EMR can demonstrate that these communications were appropriate.
Texts and phone conversations can also be summarized in the client record. You must ensure that you document the date the communication occurred, as well as the date when you created the documentation. Summarizing means you can record the main points of the discussion such as what you discussed, their response, and any actionable items that came out of the discussion. It is not a transcript of the conversation but you may be much more detailed if the nature of the conversation requires it, such as a critical finding on diagnostic imaging or a follow-up from an adverse event that occurred during care as opposed to a conversation about a scheduling conflict or a change of parameters for an exercise.
The person You communicated with
Whether it is the client, the funder, another health professional or a 3rd party, if it pertains to client care you must record it in their client record, and you must clearly identify both the content and the person or persons involved in the communication.
Common scenarios
Below you will find a list of common scenarios including forms of communication and reasoning behind why documenting communication is important.
| Scenario | Do you chart it? | Why are you charting it? |
|---|---|---|
Lawyer calling to get access to a client’s chart record |
Yes |
Any requests for access and provision of access to a client’s medical record should be captured in their chart. This would include the client’s consent to release the medical record. |
Phone conversation with a funder regarding the clients return to work plan |
Yes |
This has a direct impact on client care. You would chart the nature of the discussion and any follow-up communication with the client to relay any changes to their return-to-work plan. |
Email from a funder regarding lack of coverage for the client’s care |
Yes |
This will have a direct impact on the client’s care and should be put into the client’s record. |
Checking in on a client |
Yes |
You may be calling to check in on the client for many reasons but you are addressing their care and, therefore, it must be included in their chart record. |
Cancelling Appointments |
Yes |
You must track attendance including declined, missed, or cancelled appointments. |
Discussion about increased symptoms after a treatment session |
Yes |
You must document the client’s report of increased symptoms and any advice given on managing the symptoms. |
Conversation with another health-care provider relating to client care |
Yes |
You are discussing the client’s care including goals, barriers, or alterations to the treatment plan. |
The College of Physiotherapists of Alberta has long stated that communication with clients regarding their care must be documented. The updated Standards of Practice explicitly highlight that message. Documentation of all communication increases client safety, reduces the likelihood of miscommunications, and supports quality care. Any discussions with your client related to their care must be documented in the client record. If you are unsure whether you should document communication with your client, pause and document it.
For more information on documentation you can access the following resources.
Risk and Expectations Regarding Documentation
What Makes a Complete Client Record?
Documenting Client Communications Infographic
