Regardless of where physiotherapists have been trained or work, charting has been a consistent expectation for clinicians. As registered physiotherapists, the Standards of Practice clearly lay out the charting performance expectations for physiotherapists in clinical practice. The Documentation and Record Keeping Standard states that physiotherapists are to maintain documents/records that are accurate, legible and complete, written in a timely manner, and in compliance with applicable legislation and regulatory requirements.1
We know that most clinicians would rather treat patients than write about treating patients. We know you think you do it well and find it hard to imagine I would need to write a Good Practice article on the topic. However, the reality is practice advice calls and email questions to our office suggest differently. These questions may come from members, the public, lawyers and third-party payors. Discussions with Physiotherapy Alberta’s Complaints Director also suggest that not all physiotherapists chart in a manner that complies with Physiotherapy Alberta’s Standards of Practice or with legislation in Alberta.
Why is charting important?
It really is simple. Charting is a mandatory performance expectation of all regulated health-care providers, including physiotherapists. Charting is not optional.
The purpose of charting is to:
Convey patient health information to other health-care providers and stakeholders
Document chronological evidence of interventions, patient status, and progress in a complete and timely manner
Ensure accurate health information is accessible to the patient and any third-party stakeholders who request or require it
Provide evidence and justification of effective and medically-necessary treatment provided
Demonstrate compliance with professional, legislative, and employer regulations
Provide information to a variety of stakeholders for program evaluation/quality assurance initiatives and service utilization assessments to support the development of new programs, maintenance of existing programs, and to support the payment for services provided2
DOCUMENTATION IS EVIDENCE.3 From a legal and legislative point of view if it isn’t charted or recorded in some way – it did not happen. In both legal proceedings and College complaint investigations the patient health record is considered a legal document. The complete patient record is the primary component of every investigation undertaken when a complaint is lodged against a member’s practice. The patient record becomes the basis of your defense.3 Often these proceedings do not arise for years after the event and relying on your memory to report on the events leading up to the complaint is not good enough. Timely, accurate records are essential in establishing the care that was provided.
Remember that in a legal or disciplinary action the complainant uses the patient health record to prove that the standard of care was breached (someone did something wrong) and the respondent uses the record to prove that the standard of care was met (no one did anything wrong).3 If the record is incomplete, illegible or inaccurate it becomes very difficult for the defendant to support their practice and any discrepancies or inaccuracies can be used to discredit your testimony.3
What must be included in the chart note?
Regardless of the type of charting used, paper or electronic, the chart record must be reflective of the services provided at each intervention throughout the episode of care and anyone reviewing the health record must be able to determine:
To whom it happened
By whom it happened
When it happened
Why it happened
The result of what happened”3
As per the Documentation and Record Keeping Standard, essential elements of all charting include detailed chronological information regarding the:
Reason for attendance
Dates of each treatment session or interaction, including missed or cancelled appointments and telephone or electronic contacts
Assessment findings, treatment plans and functional goals
Details of the interaction, including subjective observations, the treatment provided, the patient response to treatment and the results of any objective treatment provided
Details of any client education, advice provided and any communication with or regarding the patient1
So why do physiotherapists struggle with charting?
The rationale for and the importance of completing accurate, timely and thorough charting from a health-care perspective is generally well recognized by physiotherapists.4 So why is it such a struggle?
The article by Harman et al2 identifies some barriers to charting as reported by physiotherapists participating in the focus groups. Factors related to time constraints were among the most commonly reported barriers and were considered some of the most important reasons why good charting was not always completed. These factors include:2
Actual time allowed for a treatment visit and the sense of responsibility to spend more time directly with patient versus charting time was clearly identified as an ongoing reason for not charting properly. The participants commonly identified that “time is money in private practice” and saw little or no return on the time invested in charting. To chart on every change in treatment, patient status, or goal would take time they did not feel they had, so they did not chart.
The time it takes to translate clinical reasoning and decision-making thoughts into words on the chart. Participants in the focus groups made statements like “I think it, but I don’t often write it” and “it’s all in my head.”2
The time it takes to convert an impairment goal to a patient-centered functional goal. The participants identified that it takes time they do not have to think through the clinician identified impairment goals and reword them as functional goals.
The actual length of the time to complete an episode of care and the speed with which goals were achieved. The participants reported charting less for clients who move quickly and as expected through the treatment plan than those who move more slowly or make less progress. Charting only when treatment did not go as planned or “by exception” was easier, took less time and was considered sufficient.
A final barrier identified by the participants in the Harman study was a fear of failure. This fear was related to the challenge of developing a treatment plan, setting goals and identifying timelines to achieve outcomes to facilitate making a prognosis. The common feeling reported was that failure to achieve these goals and outcomes in the time allotted negatively affected both the physiotherapist and the patient and resulted in a disinclination to complete goal-directed, time-specific treatment notes.2
What are some common issues related to poor charting?
One common challenge reported by the Complaints Director is illegible, hand-written chart notes. If the requested records are not part of an electronic medical record, it is routine practice for investigators to request the notes be professionally transcribed, with costs born by the member. This ensures that the content can be read and that all abbreviations are defined and understood.
Another challenge is health records that do not have chart notes for each intervention or where chart notes are not presented chronologically. Every treatment intervention needs to be recorded accurately, completely, sequentially and in a timely manner. Simultaneous charting is always considered best practice.3 This ensures that there is no confusion as to what happened, when it happened and how the response to treatment affected future care. Chart notes that are out of order or late, or notes that are missing entirely presents a confused, unclear picture of care and, in the case of an investigation creates negative implications as to the quality of care provided.3 Make sure that if a chart note must be added out of order it is clearly identified as a late entry and with the date the actual intervention occurred.
Not recording all the information related to a visit or encounter concisely, factually and clearly presents another challenge for the reader. This is true whether it is a colleague taking over the care of a patient, a lawyer, or a member of a hearing panel making decisions related to a complaint. All these individuals require a complete patient record. Use of vague phrases like “as above,” “everything normal,” “neuro exam ok” or “discussed discharge” provides no specifics about the encounter.
Simply cutting and pasting or pulling forward a previous note with no current subjective and objective notes is not sufficient. This practice may suggest that the physiotherapist is not paying attention to the accuracy of their charting and is simply putting something on paper because they are supposed to. It may also lead the reader to question the accuracy and credibility of the entire record.
It is also important that members reflect on the risks associated with the use of smart phrases or tick box charting common in electronic medical records. These shortcuts may make charting faster and easier, but can you confirm that you have had the conversation required to obtain informed consent or that you completed the assessment each time you have ticked the box or called up the smart phrase? When using these systems, it can be easy to tick the box without really thinking about the quality and thoroughness of your patient interaction. It’s much harder to write something that did not actually happen when you’re doing it long-hand.
If you have not documented any objective findings, how would you prove that your treatment was effective? How would you demonstrate your clinical reasoning and justify your clinical decisions to another individual? If you only report negative findings on tests or outcome measures, how would you prove that you completed a comprehensive and thorough exam?
It is also important to be aware that the Health Professions Act (HPA) Section 56 of the Act5 gives the Complaints Director the authority to initiate a complaint against a member. If it has been determined that poor charting constitutes unprofessional conduct the Complaints Director may treat the information, notice, or non compliance as a complaint and act on it.5
Charting is a big deal and not optional
As regulated professionals, physiotherapists are expected to ensure patient health records are accurate, legible and complete, and written in a timely manner. Simply saying “I did not have time to chart on my patients” or “I thought about it but did not write it down” will not be accepted as a defense when a complaint is lodged or a request for a complete patient record is made by a lawyer or a third-party payor. There is also no excuse for illegible written notes. If you struggle with writing, grammar or spelling find a solution that will address these issues. Use a recorder and have your notes transcribed, use electronic charting systems or try slowing down and taking more time when completing your chart notes. Find ways to incorporate simultaneous charting into your schedule. Taking five minutes out of a treatment session to reflect on what just happened and make plans for the next visit is time well spent. It adds to, rather than takes away from, providing quality care to your patients.
Although, Physiotherapy Alberta recognizes that there are challenges to charting, physiotherapists are expected to develop and implement strategies that will ensure charting is always completed in compliance with all Standards of Practice.
Physiotherapy Alberta College + Association (2017). Standards of Practice: Documentation and record keeping. Available at https://www.physiotherapyalberta.ca/files/practice_standard_documentation_record_keeping.pdf .
Harman K, Bassett R, Fenety A, Hoens A. (2009). ‘I think it, but don’t often write it’: The barriers to charting in private practice. Physiother Can. 2009;61;252-258.
Payne ME, & De Wit M. (2013). Documentation and Charting: Best practices for reducing liability. Ontario Hospital Association webinar Nov. 2013. Accessed Dec 6, 2018.
American Physical Therapy Association (2018). Defensible Documentation. Available at http://www.apta.org/DefensibleDocumentation/Overview/ Accessed Dec. 6, 2018.
Government of Alberta (2002). Health Professions Act. Available at http://www.qp.alberta.ca/1266.cfm?page=H07.cfm&leg_type=Acts&isbncln=9780779793440&display=html Accessed Dec. 10, 2018.
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Regulating Alberta's physiotherapy profession and acting as an association by providing member services.