Documentation did not tell the whole story
Allegation
The College investigated two allegations:
- The physiotherapist failed to address the patient’s physiotherapy needs and goals by failing to prescribe appropriate exercises.
- The physiotherapist failed to document the patient’s reported symptoms fully.
Investigation and Decision
The patient attended physiotherapy services at a private clinic for four months.
The patient requested a copy of their physiotherapy record and discovered that there was information missing from the record, in their opinion.
The patient also noted that they had not been prescribed any exercises while attending physiotherapy services.
The patient was to be interviewed but withdrew from the investigation. As complainants are parties to the proceedings under the Health Professions Act, when a complainant withdraws from the process, the Complaints Director must decide whether to continue with the investigation. In this case, the investigation continued with its data collection and interview of the physiotherapist.
Allegation 1
The physiotherapist maintained that the patient regularly performed exercises at the clinic during the provision of physiotherapy services.
The physiotherapist admitted that they did not provide the patient with exercise handouts.
The physiotherapy record was handwritten. The physiotherapist provided the patient with two transcribed versions of the physiotherapy record when asked for one by the patient. There was a two-week gap between the provision of the first version of the record and the second.
None of the handwritten or transcribed versions of the physiotherapy record contained specific and detailed information about the exercises the patient performed in the clinic or whether these exercises were to be performed by the patient at home.
Given this evidence of failure to meet the minimum standard of practice regarding documentation, the Complaints Director had to consider whether there were significant concerns about the physiotherapist’s competence or ethics or if there is a significant risk to public protection if the physiotherapist continues the alleged practice or behaviour.
The physiotherapist maintained that they did teach the patient exercises and prescribe the exercises appropriately.
The documentary evidence in the physiotherapy record did not fully support this.
It is the professional obligation of the physiotherapist to consistently and fully meet all governing legislation and Standards of Practice.
However, while the above was true, the Complaints Director did not believe that the physiotherapist’s conduct relating to Allegation #1 demonstrated significant concerns about the physiotherapist’s competence or ethics nor did the Complaints Director believe that Physiotherapist’s practice poses a risk to public safety.
Specifically, to remediate through education so that the conduct does not occur again, the physiotherapist was given a formal caution regarding this matter, and it was strongly recommended that the physiotherapist undertake each of the following recommendations:
- Review and reflect on the following Standards of Practice:
- Complete the College module titled Documentation: The Write Stuff
- Consider the benefits of providing handouts or other forms of exercise and education provided or prescribed to patients and consider whether Physiotherapist wishes to implement this approach in their practice.
Allegation 2
A thorough review and comparative analysis of the patient’s reported symptoms and those symptoms documented by the physiotherapist demonstrated to the Complaints Director that there was a substantial equivalency between the symptoms reported and the symptoms documented.
The physiotherapist erred when they provided the first version of the transcribed record to the patient in that they did not fully review and transcribe the handwritten version of the record.
The physiotherapist corrected this error with the second version of the transcribed records that they provided the patient.
Given that discrepancies were noted by the patient, the investigators and the Complaints Director, in the three versions of the physiotherapy record received and reviewed, the Complaints Director recommended that the physiotherapist review and reflect on their documentation practices and, as in Allegation #1, undertake steps to improve their documentation practices.
Specific to Allegation #2, there was some evidence that the physiotherapist did not meet the minimum expectations of the Documentation Standard of Practice in that the handwritten version of the daily entries was not legible, and the transcribed versions of the daily entries contained inaccuracies.
Ultimately, after considering all the information gathered relevant to Allegation #2, the Complaints Director believed there was insufficient evidence to support referring Allegation #2 for a hearing.
Key Message
Physiotherapists are not expected to be perfect in their documentation, but they are expected to meet the minimum performance expectations outlined in the Standards of Practice.
If a physiotherapist is producing a handwritten version of the physiotherapy record, ensure that version is legible or accurately transcribed when it is provided to another person.
Remember to document the details of treatment provided and patient response to treatment, including results of reassessments, in sufficient detail to allow the client to be managed by another physiotherapist.
Consent in a long-term care setting
Allegation
The daughter of a patient who had passed away submitted a written complaint to the College regarding the care provided by the physiotherapist to the patient during the patient’s residency in a long-term care setting.
The complainant and the physiotherapist were reminded that the College does not investigate system issues and complaints about an organization as a whole. The complainant was provided with alternate avenues to report and complain about these issues.
The information within the written complaint was thoroughly considered and the College investigated one allegation:
- The physiotherapist failed to select appropriate assessment tools, make an informed physiotherapy diagnosis, and apply intervention procedures proficiently for the delivery of physiotherapy services with the patient.
Investigation
Along with speaking with the complainant and the physiotherapist, the investigators also spoke with two of the patient’s other daughters.
A detailed review of the clinical record of the patient was performed, and this was cross referenced with audit reports relating to each entry made by the physiotherapist.
There was evidence to support that the patient withdrew their consent for physiotherapy services after the initial assessment was completed by the physiotherapist.
There was no evidence that substitute decision maker was in place for the patient.
There was evidence that the physiotherapist attempted to reengage with the patient regularly, but that informed consent was not reestablished for physiotherapy services.
The audit reports supported the accuracy and reliability of the clinical record.
Decision
The review of the evidence in this matter did not provide sufficient evidence to support the allegation. The complaint was not referred for a hearing.
The Complaints Director believed that:
- There was insufficient evidence that the physiotherapist failed to select appropriate assessment tools.
- There was insufficient evidence that the physiotherapist failed to make an informed physiotherapy diagnosis.
- There was insufficient evidence that the physiotherapist failed to apply intervention procedures proficiently for the delivery of physiotherapy services.
The clinical record did not clearly document the attempts the physiotherapist made to reengage with the patient or that consent for physiotherapy services had been withdrawn. The physiotherapist identified this as a possible gap in their documentation practices and stated that they had taken steps to address this.
This showed self-reflection and a commitment to practice improvement in the opinion of the Complaints Director.
Key Message
All physiotherapists are reminded of the following:
- The expectation in the Informed Consent Standard of Practice is that the physiotherapist will respect the patient’s right to question, refuse options, rescind consent, and/or withdraw from services at any time.
- The expectation in the Documentation Standard of Practice is that the physiotherapist includes in the client record detailed chronological information including documentation of informed consent and relevant details of the consent process reasonable for the clinical situation.
In this case, those relevant details included the patient’s withdrawal of informed consent.
Is your communication clear and can you defend it?
Allegation
Following the provision of physiotherapy services, the parent of the patient in this matter submitted a written complaint to the College. Based on the contents of the complaint, the College investigated two allegations:
- The physiotherapist did not meet the expected outcome of the Funding, Fees, and Billing Standard of Practice.
- The physiotherapist did not meet the expected outcome of the Assessment, Diagnosis, Treatment Standard of Practice.
Investigation
Allegation 1
The investigation focused on an analysis of the communication between the patient’s parent and the physiotherapist prior to the provision of physiotherapy services and the detail provided on the invoices received by the parent from the physiotherapist.
Allegation 2
The patient’s aide provided their account of the physiotherapy services they witnessed during the interactions between the patient and the physiotherapist.
This independent account was compared with the recollections of the patient’s parent and the physiotherapist.
An expert professional opinion was sought to further information the Complaints Directors decision in this matter. This is authorized under section 66(2)(b) of the Health Professions Act.
Decision
Allegation 1
There was evidence that the performance expectations of the Funding, Fees, and Billing Standard of Practice were met by the physiotherapist.
Thus, the allegation was refuted.
Allegation 1 was not referred for a hearing.
Allegation 2
There was insufficient evidence that the physiotherapist did not meet the performance expectations of the Assessment, Diagnosis, Treatment Standard of Practice.
While the patient’s parent and the physiotherapist disagreed about the physiotherapy services provided by the physiotherapist, the expert professional opinion supported the approach that the physiotherapist implemented with the patient. This impacted the confidence of the Complaints Director in proving the allegation for a hearing tribunal.
Because of this insufficient evidence and lack of confidence, Allegation 2 was dismissed and not referred for a hearing.
Key Message
The fundamental issue in Allegation 1 pertained to billing for indirect patient care time. The physiotherapist supported their position with documentary evidence in the phone text and email communications that showed that they had provided the patient’s parent with a clear breakdown of their fees for physiotherapy services and that this included direct and indirect patient care time.
Regarding Allegation 2, the College is clear in its communication with the public that the College does not get involved in directing a patient’s care plan. When disagreements occur regarding a physiotherapy care plan, physiotherapists should consider whether they have fully explained their rationale for their proposed care to the patient, or in this case the patient’s parent, and whether they can defend that rationale when challenged.
Privacy Breach
Allegation
After previously terminating the therapeutic relationship with the physiotherapist and requesting not to be contacted again by the physiotherapist, the patient received an email from the physiotherapist.
The email contained the names and email addresses of several other people as well as the patient.
The College investigated two allegations:
- The physiotherapist failed to protect the patient’s email address and name in a group email sent in October 2025.
- The physiotherapist communicated with the patient via email in October 2025 after the patient terminated their therapeutic relationship.
Investigation
The investigation collected submissions from the patient and the physiotherapist and interviewed the patient.
The physiotherapist was aware that the breach occurred almost immediately after it occurred and took the appropriate steps to notify patients, their employer, and the Office of the Information and Privacy Commissioner.
The physiotherapist produced the report submitted to the Office of the Information and Privacy Commissioner that detailed this breach.
The physiotherapist admitted to making a mistake when they copied names and emails from their database to a group email that contained educational materials for general consumption.
The physiotherapist admitted that they pasted the names and email addresses into a non-blinded section of the email, thus exposing the names and email addresses of all recipients to all recipients.
The physiotherapist apologized and identified steps that they had taken to learn from this error to improve their practice.
Decision
With strong evidence to support both allegations and the admission to both allegations by the physiotherapist, the Complaints Director had to consider whether the behaviour rose to the level of unprofessional conduct warranting referral to a hearing.
Physiotherapists are human and errors do occur.
While the Complaints Director agreed that the evidence demonstrated that there was a privacy breach and that the patient did not want to be contacted by the physiotherapist following their discharge, the fact that the email contained generic educational material for a wide target audience lessened the Complaints Director’s concern about the physiotherapist’s actions.
The physiotherapist stated remorse and described steps they have taken to prevent this type of incident from occurring again. This demonstrated self-reflection and a commitment to learning from this matter.
Despite the above, the College takes a breach of its Standards of Practice very seriously.
The Complaints Director provided the physiotherapist with a formal caution regarding this matter which will remain on the physiotherapist’s registration record.
The Complaints Director also recommended that the physiotherapist complete the following to improve their practice relative to the allegations investigated:
- Review and reflect on the Privacy and Record Retention Standard of Practice.
- Review and reflect on the Privacy Guide for Alberta Physiotherapists.
- Participate in the upcoming College webinar titled: Ask Us Anything - Physiotherapists and the Health Information Act.
- Review and reflect on the Communication Standard of Practice.
- Ensure processes are in place to flag those patients that do not wish to receive any communication following their discharge from physiotherapy services.
Key Message
All physiotherapists must ensure that their communication practices follow the wishes of their patients and the relevant pieces of privacy legislation.
In the event of a privacy breach, ensure you follow the appropriate pieces of privacy legislation regarding the actions you must undertake.
Did the information documented accurately reflect the patient encounter?
Allegation
The patient submitted a complaint to the College after reviewing a Form AB-4 that was completed by their physiotherapist.
The College investigated one allegation:
- The physiotherapist completed a Form AB-4 for the patient that did not accurately reflect the assessment, treatment, advice, and client encounter that occurred.
Investigation
The patient was interviewed twice and described their functional status and pain levels at discharge and currently.
The physiotherapist provided a written statement and described, to the best of their recollection, the patient’s functional status and pain levels at discharge.
The physiotherapy record was reviewed and analyzed. The physiotherapy record was reliable as there was evidence of contemporaneous documentation, and the daily entries and forms were all signed on the date of attendance or date of form completion.
Decision
As is often the case in professional conduct matters, the patient and the physiotherapist had distinctly different recollections of the events that occurred.
As is also most often the case, no recordings or witness statements were available as independent evidence of what occurred.
The Complaints Director analyzed the episode of care and the documentation that supported a progression in functional status and a reduction in pain.
Given the physiotherapy record was considered a reliable source of evidence in this matter due to its contemporaneous nature and that all entries and forms were signed on the date of attendance or form completion, there was insufficient evidence that the physiotherapist did not document an accurate encounter when they completed the Form AB-4.
The allegation was not referred for a hearing as there was insufficient evidence to support the allegation.
The complaint was dismissed.
Key Message
After reflecting on this matter, the primary motivation behind the patient complaint was, in the Complaints Director’s opinion, that the physiotherapist did not review the contents of the Form AB-4 with the patient prior to submitting the form to the insurer. This, ultimately, impacted the patient's ability to access further medical services in the patient’s opinion.
While reviewing the contents of a Form AB-4 is not required under the Diagnostic and Treatment Protocols Regulation, physiotherapists are required to communicate with their patients about what the physiotherapist will be reporting to a third party. It should not come as a surprise to a patient when a physiotherapist makes a recommendation or reports on a patient’s status.
While this can be challenging in cases where issues are contentious, it is still the physiotherapist’s professional responsibility to communicate effectively and truthfully with their patient.
Was an assessment performed prior to physiotherapy services being initiated and were the patient’s comments and feedback taken into consideration?
Allegation
The patient made a written complaint to the College that the physiotherapist utilized shockwave without performing an assessment and that, when the patient gave feedback about two exercises the physiotherapist had prescribed, the patient feedback was not taken into consideration.
The College investigated two allegations:
- The physiotherapist did not complete a physical examination relevant to the patient’s presenting symptoms.
- The physiotherapist did not ensure that the patient’s perspective and preferences were heard and understood regarding the prescription of the following exercises: clamshell and a version or variant of a calf raise off a stair.
Investigation
The investigation focused on comparing the submissions of the patient and the physiotherapist.
A physiotherapy support worker (“PTSW”) was involved in the provision of physiotherapy services with the patient and was interviewed.
The physiotherapy record was reviewed to provide documentary evidence of the events that occurred.
Decision
Allegation 1
There was evidence collected that supported and an admission on the part of the physiotherapist that they did not complete a physical examination relevant to the patient’s presenting symptoms.
The patient came to the physiotherapist with a referral from their podiatrist for shockwave for plantar fascia pain. The physiotherapist, after completing a subjective history, asked if the patient wanted to receive shockwave as an intervention. The patient said yes. Shockwave was administered by the PTSW.
The physiotherapy record contained no objective information to support the use of shockwave.
Allegation 2
There was evidence collected and an admission from the physiotherapist that they did not ensure that the patient’s perspective and preferences were heard and understood regarding the prescription of the following exercises: clamshell and a version or variant of a calf raise off a stair.
The physiotherapy record contained no objective information to support the prescription of any exercises, never mind the clamshell or a version of a calf raise off a stair.
The PTSW was assigned to teach the patient the exercises. When the patient informed the PTSW of past difficulties and symptom exacerbations with these two exercises, the PTSW modified the exercises. While this modification by the PTSW was acceptable, there was no documentation that the exercises were modified, there was no documentation of informed consent for the involvement of a PTSW in the provision of physiotherapy services, and there was no documentation to support what portion of the physiotherapy services provided were provided by the physiotherapist and what was provided by the PTSW.
Given the strength of the evidence, the Complaints Director considered referring the complaint for a hearing tribunal. After considering this and communicating with the patient, Facilitated Resolution was proposed. The patient and the physiotherapist agreed that Facilitated Resolution would achieve the goals of the professional conduct process, namely remediation of the physiotherapist’s behaviour and improvement in the physiotherapist’s practice.
The physiotherapist agreed to complete two reflection papers, each at least 1000 words long and not generated in any way by artificial intelligence on the following subjects:
- The importance of completing an assessment as required by the Assessment, Diagnosis, Treatment Standard of Practice.
- The importance of effective communication with their patients and PTSWs regarding modifications to a prescribed exercise, when indicated by the patient’s response to the exercise, once the teaching of the exercise has been assigned to the PTSW. This reflection paper is also to include reflection on the importance of documenting the adverse or unexpected response of the patient to the exercise and the modifications considered or utilized with the patient.
The physiotherapist also agreed to submit two physiotherapy records that demonstrated their learnings regarding the importance of completing an assessment as required by the Assessment, Diagnosis, Treatment Standard of Practice.
Key Message
Physiotherapists often receive requests from patients for specific interventions. The physiotherapist is still responsible for following the Standards of Practice in these situations and must ensure that any decisions relating to interventions used or exercises prescribed should flow from the results of an assessment. Ensure that there is documentary evidence in the physiotherapy record to support your clinical judgement.
The use of PTSWs is integral to the provision of physiotherapy services. However, inappropriate use of PTSWs is becoming a theme at the Complaints Director’s desk. All physiotherapists that assign physiotherapy services to PTSWs must be aware of the physiotherapist expectations within the Standards of Practice that involve the use of PTSWs.
Words Matter
Allegation
The patient attended physiotherapy services with the physiotherapist twice.
On the second attendance, the physiotherapist said words to the effect of “so what did we do last day?”
The patient submitted a complaint based on this statement, that the physiotherapist did not know what physiotherapy services were provided and what the plan for the second attendance was.
The College investigated one allegation:
- The physiotherapist failed to meet the expected outcome of the Documentation Standard of Practice.
Investigation
After making the initial written complaint, the complainant did not respond to the College’s investigators attempts to conduct an interview. The investigation continued without the involvement of the complainant.
The physiotherapist provided their version of events, the physiotherapy record, and also described changes the physiotherapist had made to their practice as a result of this complaint.
Decision
There was evidence collected that supported the allegation in that needles were used in practice on the first attendance but that this was not documented in the physiotherapy record until the physiotherapist made an addendum to the record.
The physiotherapist made the addendum after receiving notice of the complaint from the College. While technically correct to make an addendum to the record once a documentation error has been noted, the timing of the addendum and the College investigation was notable.
The physiotherapist admitted they erred by not documenting the use of needles on the first day.
The physiotherapist described audit measures they had undertaken to limit the occurrence of this type of error occurring again.
The physiotherapist also provided reflective comments on their choice of words in this case and recognized how saying “so what did we do last time” or words to that effect might impact a patient.
The physiotherapist committed to improving their practice and modifying their choice of words when asking about a patient’s response to the prior physiotherapy attendance.
Ultimately, while there was evidence to support referring the matter for a hearing, the Complaints Director determined that a one-time documentation error did not rise to the level of unprofessional conduct in this instance.
The complaint was dismissed.
Key Message
Choose your words carefully and consider their impact, as comments that seem innocent or normal to you may not be perceived the same way by others. The College expectation is that all communication is professional, clear, effective, and timely to support and promote quality physiotherapy services.
Consider implementing audit measures for your documentation to ensure that you are not inadvertently missing documentation.
Respecting boundaries and individual comfort levels
Allegation
This complaint was made under section 57 of the Health Professions Act following the termination of an employment contract of a physiotherapist by their employer for conduct the employer deemed to be unprofessional conduct.
The allegation investigated by the College was:
- The physiotherapist failed to conduct themselves professionally when interacting with a colleague.
Investigation
The employer provided the letter of termination issued to the physiotherapist as well as a statement from the physiotherapist’s colleague about the interaction between the physiotherapist and the PTSW.
The physiotherapist provided the investigator with their version of events and their recollection of the interactions between them and the PTSW.
Decision
There were no witnesses to any of the interactions between the physiotherapist and the PTSW.
The employer stated that they did not investigate the conduct of the physiotherapist prior to terminating the employment contract.
The PTSW indicated to the employer that they did not wish to be reminded of this matter going forward.
The lack of involvement of the PTSW impacted the Complaints Director’s ability to collect further evidence in this matter.
The College is committed to a trauma informed approach to its professional conduct processes. Considering this, and the likelihood that the PTSW would report fundamentally similar events to a College investigator as they did to their employer, the Complaints Director determined it was neither necessary nor followed a trauma informed approach to interview the PTSW.
The physiotherapist admitted that some of their comments and actions could have be misinterpreted and apologised for any misinterpretation.
As there was no direct patient involvement in this matter, and the physiotherapist had already seen a punitive response from their past employer, the Complaints Director, while concerned about the reported behaviour of the physiotherapist, did not believe there was sufficient evidence nor sufficient concern about the physiotherapist’s ethics to warrant referral of this matter for a hearing.
The complaint was dismissed.
The Complaints Director recommended that the physiotherapist complete the following to improve their practice:
- Review and reflect on the Boundary Violations Standard of Practice.
- Review and reflect on the College’s Managing Challenging Situations Guide for Alberta Physiotherapists.
The Complaints Director also noted that the physiotherapist must complete the College’s Sexual Abuse and Sexual Misconduct education module as part of their ongoing registration requirements. The Complaints Director noted that this will serve as a good reminder regarding the possible blurring of lines with patients and co-workers and provide the physiotherapist with strategies to prevent possible boundary violations.
Key Message
Physiotherapy is a touching profession, and individual comfort levels can vary.
Physiotherapists should remain attentive to how their words and actions may be received by others and should take care to maintain appropriate professional boundaries in all workplace relationships.
