Good Practice: Documentation and Record Keeping

  •   May 6, 2021
  •  Nancy Littke, PT

Over the years Physiotherapy Alberta has published several articles and resources discussing the importance of keeping accurate, legible, and complete patient records. In these articles we have discussed the importance of documentation being written in a timely manner and of complying with legislation and regulations. Most recently, in the January 2019 Good Practice Article, “Why is Charting Such a Big Deal?”, we looked at the purpose of charting from a clinical, legislative, and professional perspective.1 This article also outlined what is required in a complete chart note, some reasons why clinicians struggle with charting and a few common issues related to poor charting and the subsequent consequences for patient care and/or the physiotherapist.

So, why are we writing another article on charting? Charting issues are very common in the conduct world. In conversation with the Complaints Director and Conduct Coordinator, documentation continues to be the source of, or a factor in, a number of conduct investigations and complaints. Currently one third of active conduct files have documentation as the primary complaint or as a component of the complaint.

In this article we highlight some of the common documentation issues seen in physiotherapy conduct files. We know that this topic is one that many people find dull or would rather avoid, so we have framed the information as a quiz. Test yourself or your colleagues and see how you do. Don’t worry, it’s just for fun, no marks involved.

Questions

  1. I know I am supposed to chart on all patients, but I am just so busy. Not charting on some patients is fine.
    1. True
    2. False
  2. I do not have to write down everything that happened because I know what I did and what my plans are for the next visit.
    1. True
    2. False
  3. It is acceptable to copy previous notes into my current session chart note.
    1. True
    2. False
  4. I forgot to chart on a session from last week. It’s ok to simply add in a note and back date it.
    1. True
    2. False
  5. I should avoid making judgmental, or biased/biasing comments, like referring to a patient as lazy, non-compliant, unfocused, unmotivated, addicted, or other similarly subjective statements in a patient’s record.
    1. True
    2. False
  6. Handwritten notes are acceptable.
    1. True
    2. False
  7. I can delay or deny providing a copy of a patient record when requested, especially if the note is not complete and I need to update the record.
    1. True
    2. False

Scroll down to see the answers.

 

 

 

Answers

  1. I know I am supposed to chart on all patients, but I am just so busy. Not charting on some patients is fine.

Answer: FALSE As regulated health-care professionals, physiotherapists are expected to ensure patient health records are accurate, legible, and complete, and written in a timely manner. This means charting needs to be completed everyday, as close to the time-of-service delivery as possible. This expectation is clearly outlined in the Documentation Standard of Practice and is not an option. Not having enough time or planning to chart in the future are not acceptable excuses for poor charting practices.

Failure to document in alignment with the Standards of Practice and Code of Ethical Conduct can be considered unprofessional conduct. Although not common, some of the current complaints against physiotherapists are related to a total lack of documentation on a patient file.

  1. I do not have to write down everything that happened because I know what I did and what my plans are for the next visit.

Answer: FALSE The chart note must contain all the information another physiotherapist would need for them to be able to continue your treatment plan, understand your clinical decisions, or support your practice at a future date.

Vague comments, missing conversations or consent discussions, providing inaccurate information to make the chart read better, or only charting part of the information because you think you will remember the rest is not acceptable. This type of charting puts patients at risk and puts you at risk if you were required to explain your practice in a conduct investigation following a complaint. Investigations frequently include he said/she said disparities. Remember, in a hearing or investigation, if it is not written It is assumed to not have happened or at best viewed as suspect.

  1. It is acceptable to copy previous notes into my current session chart note.

Answer: FALSE Many electronic platforms allow for a previous chart note to be pulled forward or may even automatically populate the new chart note with the previous information. Although this may appear to save valuable time, it does not meet the charting expectations of accurately documenting all relevant information.

It would be very unusual for one visit to proceed exactly as the previous visit did. This would certainly be unreasonable over several visits in a row. Consider how it appears to the reader when over half of a patient's entries are just copied from the previous notes. This could certainly cause the reader to question the validity, accuracy, and credibility of what was written. The practice suggests that the physiotherapist is not paying attention to their charting and is simply putting something on paper because they are supposed to. It could be seen to indicate that they are not meeting professional expectations of reassessing patients and appropriately progressing treatment plans.

While this function of electronic platforms enables the physiotherapist to copy the contents of a previous note if the treatment plan is unchanged, there is an expectation that the provider will comment on the patient’s subjective report or updated objective observations at each treatment session and update other details to avoid recording an inaccurate note. Pulling forward a chart note is only an acceptable practice when the information is subsequently updated with current details that reflect the patient’s status and progress on the date in question.

  1. I forgot to chart on a session from last week. It’s ok to simply add in a note and back date it.

Answer: FALSE Documentation must be accurate, complete, and written contemporaneously. Missed notes happen. When this is noticed, late entries must follow the same documentation practices as any other note. They must be objective, factual, accurate and transparent – including documenting what you remember about what happened on the day of service, the date of the intervention, and date the late entry was written.

  1. I should avoid making judgmental, or biased/biasing comments, like referring to a patient as lazy, non-compliant, unfocused, unmotivated, addicted, or other similarly subjective statements in a patient’s record.

Answer: TRUE The words we use in patient records or discussions with other providers or stakeholders are important and can positively or negatively influence the reader’s perception of the patient and can impact on patient care provided.3 Stigmatization is the act of treating someone or something unfairly by publicly disapproving of them.4 A study looking at stigmatizing language suggests this practice is a pathway for implicit bias being passed on from one clinician to another and may subsequently influence communication and treatment decisions.3

Using words like lazy, non-compliant, unfocused, unmotivated, or addicted in a chart note can have a detrimental affect on the way the reader sees the patient and may directly affect health-care providers’ or other stakeholders’ attitudes towards the patient and future treatment or relationships.3 Using person-first language that describes the individual as someone who has a problem is preferable.

Examples of person-first language include: person with multiple sclerosis vs MS sufferer, X is affected by obesity vs X is obese.5,6 Attention to the language used in patient chart notes is important, promotes patient-centered care, and helps reduce health-care disparities for stigmatized populations.4

It is also important to consider the effects subjective comments may have on a patient’s relationship with a third-party such as WCB or third-party payer in a DTPR case. A comment or judgement that is not supported by objective evidence may seriously bias the outcome of a claim and have long term consequences for the patient.

  1. Handwritten notes are acceptable.

Answer: TRUE You do not have to purchase an electronic medical record system, provided handwritten notes are legible.

If a chart note is handwritten and hard to read, you may be required pay to have the entire note transcribed if the record was requested as part of a conduct investigation. An illegible note may also give other professionals a poor impression of how you do your work and can be detrimental to patient care and collaborative practice. Think about how frustrated you become when you cannot read another health-care professional’s documentation or referral.

  1. I can delay or deny providing a copy of a patient records when requested, especially if the note is not complete and I need to update the record.

Answer: FALSE Privacy legislation requires that requests for patient records be responded to in a timely manner. The timelines for chart release are 45 days under the Personal Information Protection Act7 or 30 days under the Health Information Act.8 There are very few reasons that would permit a physiotherapist to refuse the request. None of these reasons include the need to catch up on past chart notes, make corrections or changes to existing notes, or to write an entire patient record because no notes exist. Release of patient records is a frequent item of concern when members of the public, lawyers, and/or third-party payers call the Conduct Coordinator or Practice Advisor. More information related to releasing patient records can be found in the June 2019 Good Practice Article Releasing Patient Information.

Factors that may affect documentation practices

We often hear from members who feel that documentation is not a priority. Others argue that charting takes time away from direct patient care.

During a complaint investigation, two of the most common reasons members provide for poor or substandard charting are time constraints and challenges fitting charting into the day. This attitude may be due to a lack of appreciation or understanding of how documentation impacts patient care. These factors are discussed in more detail in the January 2019 article.

Physiotherapists may sometimes find themselves struggling with charting when events in their personal lives affect their work performance. It is not uncommon for stress at work to cause tension and stress in one’s personal life. However, this situation can also work the opposite way. Personal, financial, family, or mental health challenges can carry over to work affecting our ability to focus and negatively affecting performance.9

Ultimately, these challenges/circumstances do not override the responsibilities and requirements established in the Code of Ethical Conduct, Standards of Practice, and Alberta legislation. While many physiotherapists may face these challenges, when they arise, they should serve as a red flag that the physiotherapist is at risk and needs to seek supports from their peers, supervisors or others.

Summary

How did you do on the quiz? Do any of the situations feel familiar? When you reflect on your charting practices or review patient records do you see evidence that your charts may not be as complete or accurate as they should be? Do you feel that stress at home or in the workplace is affecting your job performance? If you answered yes to any of these questions, it may indicate the need to develop a plan to address the issue. This may include a conversation with a mentor, colleague, or your employer. Looking into supports available through employer-funded assistance programs may also be helpful.

Each year you are expected to identify and work on a Self-Selected Continuing Competence Activity. Auditing your own charting and developing a strategy to address any weaknesses may be an activity to consider this year.


  1. Physiotherapy Alberta College + Association. 2019 Good Practice: Charting: Why is it such a big deal. Available at https://www.physiotherapyalberta.ca/physiotherapists/news/good_practice_why_is_charting_such_a_big_deal
  2. Healthcare Insurance Reciprocal of Canada (2017) Strategies for improving Documentation: Lessons from Medical-Legal Claims. Available at https://www.hiroc.com/system/files/resource/files/2018-10/Documentation-Guide-2017.pdf
  3. Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record. Available at https://rdcu.be/cfbbD
  4. Cambridge Dictionary: Stigmatization definition. Available at https://dictionary.cambridge.org/dictionary/english/stigmatization
  5. Employer Assistance and Resource Network on Disability Inclusion. People-First Language. Available at https://askearn.org/topics/retention-advancement/disability-etiquette/people-first-language/
  6. Obesity Canada. How to use people-first language. Available at https://obesitycanada.ca/oc-news/use-people-first-language/
  7. Government of Alberta (2014) Personal Information Protection Act. Alberta Queen’s Printer. Available at http://www.qp.alberta/documents/Acts/P06P5.pdf. 
  8. Government of Alberta (2020) Health Information Act. Alberta Queen’s Printer. Available at https://www.qp.alberta.ca/documents/Acts/H05.pdf
  9. Casey J. The top 10 causes of unprofessional conduct. Alberta RN. 2006;62(4):4-6. Available at https://www.acslpa.ca/wp-content/uploads/2019/05/Top-Ten-Causes-of-Unprofessional-Conduct.pdf
  10. Personal conversation: Moyra McAllister, Complaints Director Physiotherapy Alberta College + Association.