The College regularly hears from clients and physiotherapists alike who are unsure of what should be included in a complete client record when a copy of the record has been requested. Our goal is to provide a better understanding of what is required when releasing a complete client record regardless of who initiates the request. In a prior article about privacy, we met Joe. Joe was a lovely individual who had recently undergone hip surgery after a fall at work. We are going to retrace some of Joe’s journey to discuss the different components of a client record and what must be provided when Joe asks for a copy of his record.
Let’s retrace Joe's steps through his treatment journey and focus on his request for a copy of his complete client record to create a better picture of what needs to be included before providing it to Joe.
Joe’s surgery was successfully completed at the hospital, and he benefited from a short stay as an in-patient prior to being discharged home. He was receiving care at a private clinic afterwards for his post-op rehabilitation. He spent several months attending the clinic and decided it was best for him to leave town so that he could be closer to his daughter. He asked for a copy of his client record so that he could provide it to his new physiotherapist and physician near his new home.
What is the basic information that should be included in his complete client record?
Each client record must contain the following information according to the Documentation Standard of Practice. These are the basic things that belong in a client record:
- Sufficient details of clinical care to allow the client to be managed by another physiotherapist
- Records of client attendance, including declined, missed, or cancelled appointments
- Financial records
- Details or copies of all incoming or outgoing verbal or written communication with or regarding the client
- Details regarding disclosures of client health information to another party including who the information was disclosed to, what information was disclosed, for what purpose, and on what date.
To structure the rest of this article, we are going to look at some different questions about releasing a copy of Joe’s record from the perspective of different people involved.
Front Desk
Do I include all of the intake information Joe filled out on his first day here?
The initial intake forms may be commonplace, but they provide important information about Joe, his medical history, and other essential details, so they should be included in his client record. He filled out an intake form which included a medical screening questionnaire, a consent form, and he supplied insurance information relating to his WCB claim as well. All of these forms should be included in the copy of Joe’s client record.
What about the consent forms that were filled out during his treatments here?
Recall that at the start of Joe’s attendance in clinic, he had his daughter along as a designated co-decision maker. Regardless of who is providing consent to the treatment being received, consent must be documented and included in the complete client record.
Informed consent can be written or verbal. While the law does not generally require a “written consent”, a consent form signed by Joe or his daughter provides evidence that consent has been obtained. All written consent forms would be included in the complete client record. If during the course of treatment there were instances of obtaining verbal consent from Joe such as verbal consent for ongoing treatment or a change to the treatment plan it would be documented in the client record.
Whether the physiotherapist accepts verbal consent or has the patient sign a consent form, the physiotherapist is expected to document the consent process including the information provided to the patient, and when/how consent was obtained. All of this information is part of a complete chart copy. You can find more information in the Consent Guide.
Should I include his payment records for his treatments as well as the exercise bands and weights he bought for his home program?
Yes, financial records are included in the complete client record. The client may require these for insurance purposes, tax records, etc. so they are automatically included in what you are giving Joe. You should also include the fee and the forms filled out by Joe to produce the client record as part of this.
Physiotherapist
I ordered an x-ray for Joe while he was here and got the results directed to me so that goes into his record, but what about the x-rays from the hospital and the surgical report? They were sent here in his first few weeks of treatment, but the originals are at the hospital and on Netcare.
The answer is yes, you include any diagnostic imaging, surgical reports etc. that you have related to Joe. This type of information constitutes communication about the client and is one of the required elements of the client record. From the client’s perspective they would expect you to have the information that was sent to you on record, the client has the right to access that information and providing these reports is much more client-centered than having him run around to several different locations putting the pieces together on his own.
He was a WCB client so do I include his WCB reports?
Neither the WCB Act nor the WCB contract prevent the release of a client record or other information to the client. As a rule, the information collected from a client is viewed to be the client’s property, though the physical copy of that information (the client record) is the property of the clinic. Joe has the right to receive copies of these reports from either the physiotherapy clinic or the WCB. When the physiotherapist releases the WCB reports, it should be done as per the physiotherapist’s policies regarding access to information. The WCB has previously indicated that provided that the physiotherapist adheres to applicable legislative obligations, “additional permission from WCB to release this information to a third party is not required. This includes file copies of WCB report forms.”
In relation to contracts with other third-parties, be aware that the Health Information Act specifies that a client “has a right of access to any record containing health information about the individual that is in the custody or under the control of a custodian.” Contracts with other third parties may include clauses intended to constrain the release of client information, however privacy law still applies to that information. Physiotherapists must not enter into contracts that limit their ability to comply with their legislated duties.
When I was reviewing the client record, I noticed that there were several entries that were incomplete or missing, what do I do now?
So that is a problem. The Standards of Practice clearly state that physiotherapists have the responsibility to maintain document/records that are accurate, legible and complete, written in a timely manner, and in compliance with applicable legislation and regulatory requirements. You are now aware of the mistake and need to take action to rectify the issues as best you can. You should also go back and review other client records to see if it was just an issue with Joe or is this a sign of a bigger issue that needs to be corrected.
Any notes or portions of notes that are written after the fact MUST be identified as late entries and entered into the record on the day the note was written, not entered into the record as of the day the intervention was completed. Make sure that if an entry must be added out of order it is clearly identified as a late entry indicating the date the actual intervention occurred. Entries that are out of order or late or notes that are missing entirely present a confused, unclear picture of care and, in the case of an investigation, create negative implications as to the quality of care provided. Unfortunately, one of the potential fall outs of any notes that are written long after the intervention occurred may be that in a legal case or professional conduct matter, they may no longer be considered an accurate record of the care provided.
I found some emails that I had sent Joe when he had some questions about his exercises, do these get put in too?
Documentation should include the details of any education or advice provided to Joe. This would include the emails between you and Joe, but also any text messages or notes about phone conversations with Joe or his daughter regarding his care. Those phone conversations should have been documented at the time of the conversation and included in his client record. When it comes to text messaging, you can take screen shots of the text message chain or document the nature of the texts. Similarly, other communication about the patient, including emails or communication between the physiotherapist and their colleagues or support workers about Joe's progress and the management of his care should also be part of the client record and need to be provided in a complete client record.
I emailed and talked to Joe’s surgeon when we had concerns about his hip but didn’t keep those emails.
Those emails and conversations are also part of the client record and should have been documented and included in the complete client record. You can treat these like missing or incomplete entries. Provide a late entry of what you can recall but keep it to those things that you are sure of. As previously stated, they may no longer be considered of any value if a legal case or professional conduct matter were to be initiated.
Joe/client
“You have my date of birth incorrect; can you change it?”
According to privacy legislation, if a client requests an amendment for a factual error, the physiotherapist documents the request and corrects the error. So, if you compare Joe’s ID with what you have recorded and find an error in his date of birth then you would document the request and correct the error.
Joe will be volunteering to drive the senior’s bus after he moves and is also due for a license renewal. He notes in the client record that you felt he was still unable to drive due to his current functional level. He tells you how important it is for him to drive and wants you to change your opinion to let him drive. Can you make that change?
If the client requests an alteration to information that is factually correct or that would constitute a change to your professional opinion, it is not appropriate to make the amendment. You would still document the request to make the specific change, but you would leave the client record as is and document your reasons for doing so.
One other consideration to altering a client record would be that an amendment is not the same as a redaction. A redaction would be a full removal from the client record, which you do not do. With an amendment, the original content is still readable, and you would document both the request from the client to make the amendment and some indication of why/how you decided to make the amendment (or not, as the case may be).
It is important to remember that the client absolutely has a right to access a copy of their client record. A client or third-party can expect to receive a response to a request for a copy of the complete client record within 30 days. When responding the physiotherapist either provides the chart copy or indicates a timeline for when the copy will be provided.
The client must be informed of the estimated cost prior the request to produce a chart copy being completed. The fees must be consistent with the fee schedule established in the Health Information Regulation. The next time you get a request for a copy of a complete client record you will be able to provide exactly what is requested.
