Conduct Matters: Getting Behind on Charting, Case Study

  •   June 7, 2021

Physiotherapy Alberta received a complaint from a regulated health-care professional working in a physiotherapy practice. The complaint stated that a physiotherapist was “several months behind in patient care charting.”

In response to the complaint, the physiotherapist was forthcoming and aware of breaching the Documentation and Record Keeping Standard of Practice. The physiotherapist provided several explanations for “getting behind in charting.” And, despite attempts to improve charting timelines, they were unsuccessful.

An investigation into the allegation was conducted. The investigation confirmed lack of treatment records in some instances and, where records existed, there were other contraventions of the Documentation and Record Keeping Standard, including:

  • Recording of inaccurate information (e.g., indicating a service was provided when it was not).
    • Changing or altering an entry in such a way that the original entry could not be identified.
    • Not recording information in the record in a timely manner (e.g., backdating entries with no documentation to indicate they were late entries).
  • Not maintaining records in a secure location on the premise.
  • Removing the records from the worksite without taking proper steps to secure the records during transfers.

The Outcome

The investigation revealed there was sufficient evidence of unprofessional conduct to refer the matter to be heard before a Hearing Tribunal. As permitted by the Health Professions Act, the Complaints Director, with the complainant’s permission, decided instead to address the documentation and record keeping deficiencies using facilitated resolution.

The physiotherapist entered into a formal, binding agreement with the Complaints Director. The agreement set out the remedial actions the Complaints Director determined would address the documentation issues identified in the investigation.

Over the course of 18 months, the physiotherapist was required to:

  • Complete three learning modules on charting and record keeping
  • Undergo three chart audits
  • Pay a portion of the chart audit costs and investigation costs

The physiotherapist worked cooperatively with the Complaints Director and completed all remedial activities.The physiotherapist significantly improved in maintaining accurate timely charting and properly securing documentation indicating that Physiotherapy Alberta’s Documentation and Record Keeping Standard is now met.