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Conduct Matters: Failure to Provide a Complete Patient Record

The complaint

The College received a formal complaint from a patient stating they were unable to obtain a copy of their treatment record from their private practice physiotherapist. The complainant stated that the request had been made 47 days earlier and the physiotherapist had not released a copy their treatment record to them.

Informal resolution attempt

As a first step, the College of Physiotherapists of Alberta (CPTA) communicated with the complainant and the physiotherapist to resolve the complaint. According to the Health Professions Act (HPA), the Complaints Director may encourage the two parties to communicate with each other and resolve the matter. Resolution was unsuccessful; therefore, the Complaints Director advised the complainant and the physiotherapist that the matter required a full investigation. The complaint was processed under Part 4 of the HPA.

The investigation findings
  • The patient made numerous requests to obtain a copy of their treatment record. Requests were made in person, via telephone, via written request through their family physician, as well as a written request via email.
  • The clinic where the investigated member worked had a written policy regarding the release of patient information. The policy contained information on how to request access to a copy of the treatment record, and how the personal information is to be provided; however, the policy was not followed by the physiotherapist.
  • Although the patient’s treatment file was provided to the family physician, the copy provided was not a complete copy of the patient’s record.
  • The evidence supported that the physiotherapist was mistaken in their understanding of what comprises a full and complete treatment record.
The outcome

The role of the Complaints Director is to determine whether there is sufficient evidence of unprofessional conduct as defined in s. 1(1)(pp) of the Health Professions Act to warrant referring the matter for a hearing. Contravention of the Standards of Practice and contravention of another enactment that applies to the profession are two actions defined as unprofessional conduct.

The evidence supports that the physiotherapist did not meet the requirements of the Personal Information Protection Act nor did they meet CPTA’s Standard of Practice on Documentation and Record Keeping, specifically the expectation regarding release of the patient record. However, the Complaints Director determined that the matter did not warrant referral for a hearing.

The physiotherapist was given a formal caution that any similar professional misconduct may result in a referral to a hearing. A formal caution permanently remains on the physiotherapist’s CPTA file.

The complaints director strongly recommended that the investigated member review the following in detail:

With the physiotherapist’s consent, the Complaints Director released a complete and full copy of the treatment record to the patient.

CPTA’s Standard of Practice on Documentation and Record Keeping is based directly on privacy legislation. Services provided by physiotherapists in the private sector are governed by the Personal Information Privacy Act. It is the physiotherapist’s professional and legislative obligation to ensure that they consistently follow the privacy legislation and meet CPTA’s Standards of Practice.

Page updated: 09/06/2022