Case 1: Practicing without a Valid Practice Permit
December 24
Allegations
The physiotherapist failed to renew their registration by the due date despite numerous notices from the College.
The Registrar informed the Complaints Director, and the College investigated the following allegation:
- The physiotherapist provided professional services as a physiotherapist when not authorized to do so.
Investigation
The physiotherapist admitted they provided professional services as a physiotherapist for 35 days when they were not authorized to do so.
Decision
The Complaints Director proposed a Facilitated Resolution with the physiotherapist.
Facilitated Resolution results in a formal and binding agreement between the physiotherapist and the College.
The physiotherapist agreed to do the following:
- Review the Governing Legislation page of the College’s website in its entirety and provide confirmation to the Complaints Director.
- Review the Code of Ethical Conduct in its entirety and provide confirmation to the Complaints Director.
- Pay the $500 fine for practicing when not authorized. This fee is separate and apart from any registration fee imposed.
- Inform their employer(s) they provided professional services as a physiotherapist for 35 days in 2025, when not authorized and provide confirmation to the Complaints Director.
- Notify the payor of every client/patient that the physiotherapist provided physiotherapy services to them when the physiotherapist was not authorized to do so and provide confirmation to the Complaints Director, specifically:
- Provide the Complaints Director with a complete copy of their billing records for the 35 days in 2025 that they provided physiotherapy services when not authorized to do so.
- Develop and provide the Complaints Director with the template of a written notice the physiotherapist will provide to each payor/patient informing the party they provided services without a valid practice permit and including resolution for inappropriate billing.
- Advise the Complaints Director in writing that written notice was provided to each party referenced above.
- Renew their practice permit before September 30 every year for as long as they wish to provide professional services in Alberta.
Key Message
Being a physiotherapist is a privilege.
Renewing your practice permit is essential. Only physiotherapists with an active practice permit may provide physiotherapy services. The College allows sufficient time to renew each year and provides many reminders to do so.
Practicing without a permit impacts the physiotherapist, the patient, the employer, and payors, and could affect public confidence in physiotherapists. The physiotherapist in this case was surprised at the amount of time it took to fulfill their professional obligations as a result of their error.
In this case, any patient or payor within the 35 days, had the right to request reimbursement for the services provided from the physiotherapist. Consider the impact of this on patients, the physiotherapist, and the clinical setting.
Consider also if your malpractice insurance applies in such a case.
We all live busy lives and registration time comes at a busy time of year, but we must all maintain an active practice permit if we wish to call ourselves physiotherapists and provide physiotherapy services.
Case 2: Consent Discussions and the Importance of Documentation when Changing Physiotherapy Providers
December 24
Allegations
The patient was being treated with dry needling - intramuscular stimulation by their first physiotherapist. The patient’s care was transferred to a second physiotherapist, the investigated physiotherapist. The investigated physiotherapist continued to use needles in practice but used an acupuncture approach. The patient alleged this was not communicated clearly to them by the investigated physiotherapist.
The patient also alleged that, during a lumbar spine mobilization, the investigated physiotherapist applied force to the patient’s right shoulder which resulted in increased symptoms.
The College investigated two allegations:
Allegation #1: On January 24, 2024, the physiotherapist failed to apply physiotherapy interventions, specifically manual therapy, safely and effectively resulting in right shoulder symptoms for the patient
Allegation #2: In January 2024, the physiotherapist used dry needles in practice without the informed consent of the patient
Investigation
The investigation focused on descriptions of the manual therapy and use of needles provided by both the patient and the physiotherapist and a review of the documentation surrounding the manual therapy provided on the date in question and the documented response of the patient to the manual therapy provided, and the documentation regarding the use of needles as a physiotherapy intervention and the consent discussions surrounding the use of needles as a physiotherapy intervention.
Decision
Allegation #1
The physiotherapist and the patient had divergent recollections of the manual therapy provided and the patient’s immediate response to the intervention.
There was strong evidence to support the allegation in that the patient called the Clinic to report increased symptoms following the appointment. This call was documented by the Clinic’s administrative staff and the physiotherapist.
There was no documentary evidence to support the physiotherapist’s version of events. The physiotherapist admitted that their documentation surrounding the manual therapy provided and the immediate response to that intervention did not meet the physiotherapist expectations of the Documentation Standard of Practice.
Allegation #2
Both parties agreed and the physiotherapy record supported that dry needles were used as an intervention on the date in question.
The physiotherapist offered their explanation for their choice in needle location, retention versus immediate removal, and their rationale to support their use of dry needles in practice.
The physiotherapist also described their training and approach when using needles in practice and admitted it is a form of anatomical acupuncture and was not intramuscular stimulation in this case.
The physiotherapist admitted they did not discuss this approach with the patient. The physiotherapist admitted to not documenting consent thoroughly.
The physiotherapist committed to improving their communication and documentation in these areas.
The physiotherapy record poorly documented the location of insertion of the dry needles. The physiotherapist admitted to this behaviour and identified they will improve this in the future.
Given the evidence collected and the admissions of the physiotherapist, the Complaints Director had sufficient evidence to consider referring the matter for a Hearing Tribunal to consider, or to seek the consent of the patient and the physiotherapist to proceed with a Facilitated Resolution.
Facilitated resolution results in a formal and binding agreement between the physiotherapist and the College. The terms of the agreement are typically similar to orders the College would seek if the matter was referred for a hearing and the physiotherapist was found guilty of unprofessional conduct.
The physiotherapist agreed to the following:
- To complete and show proof of completion of the following education modules to the Complaints Director:
- Informed Consent for Physiotherapists
- Documentation
- To review the following Standards of Practice of the College and then compose a self-reflection paper of 1000-2000 words, not generated in any way by artificial intelligence, detailing how this matter has impacted their practice and the changes they have made or will make as a result of the investigation into this matter:
- Informed Consent
- Documentation
- Communication
- The following condition was placed on the physiotherapist’s practice permit until completed to the satisfaction of the Complaints Director:
- Write a self-reflection paper
Key Message
The College is clear and consistent in its messaging regarding the importance of documentation. Clinical care and record-keeping are inextricably linked and
that good medical record keeping is part of providing good medical care.
Physiotherapists should reflect on their documentation of patient responses to interventions, particularly when something unexpected happens.
When changing physiotherapists and / or treatment approaches, consent must be obtained and documented fully.
Specific to this case, do not assume that one approach to the use of needles in practice encompasses all approaches to the use of needles in practice. Our patients deserve to know the differences between an intramuscular stimulation approach to the use of needles versus an acupuncture approach.
Case 3: Did the Documentation Support the Physiotherapist's Version of Events?
January 8
Allegation
The physiotherapist intern failed to safely and effectively administer physiotherapy services to the patient when treating a neck and mid-back condition.
Investigation
The investigation focused on submissions from the patient and the physiotherapist intern, an interview with the supervising physiotherapist, and document reviews.
Decision
The patient presented with left sided cervicothoracic pain.
The physiotherapist intern performed an assessment, developed a physiotherapy impression of muscle strain, reviewed the treatment plan with the patient, and provided appropriate treatment. After treatment, when returning to sitting from lying, the patient experienced an unexpected worsening of symptoms and a corresponding reduction in function that lasted several months. The patient consulted a neurologist and was diagnosed with a C7 radiculopathy.
The investigation determined that verbal consent was received for the assessment, but this was not documented. The assessment was appropriate for the presenting symptoms but did not include a cervical scan or cervical special tests. The physiotherapist intern had a reasonable rationale for not performing these portions of an assessment on the date in question. Specific details regarding the treatment provided were recounted by the physiotherapist intern in their interview but were not documented sufficiently for another physiotherapist to be able to carry on the treatment plan.
No findings of unprofessional conduct were made. However, the physiotherapist intern was advised to review and reflect on the Documentation Standard of Practice due to noted deficiencies in their documentation
The physiotherapist intern was also recommended to consider their assessment tests, including cervical scans and special tests, going forward for patients with similar presentations.
Key Message
Documentation is typically the key piece of evidence in an investigation and professional conduct decision.
Well-maintained records can demonstrate that appropriate care was given, reduce the risk of errors, support informed decision-making and support continuous improvement in practice.
Ensure your documentation is complete and well thought out and in sufficient detail for another physiotherapist to be able to manage the case effectively.
Case 4: Pneumothorax Following Dry Needling Intervention
January 14
Allegations
The patient attended physiotherapy once. Dry needling was utilized as an intervention along with several other interventions.
The College investigated two allegations:
Allegation #1: The physiotherapist failed to safely and effectively administer dry needling with the patient resulting in a pneumothorax.
Allegation #2: after the patient notified the physiotherapist of a potential patient safety event, the physiotherapist failed to recognize this occurrence and manage the event appropriately.
Investigation
The investigator interviewed the patient and the physiotherapist and the patient’s husband as the patient’s husband interacted with the physiotherapist regarding the patient’s condition. The patient’s husband was not in attendance at the appointment to offer direct evidence as to what happened during the provision of physiotherapy services.
The patient and the patient’s husband both stated that the patient told the physiotherapist after having dry needling utilized “I swear you hit my lung.” The physiotherapist denied that the patient said this.
The investigation revealed that the patient stayed in the clinic for other physiotherapy interventions for 30 to 45 minutes following the dry needling intervention.
The patient stated that they felt some pain relief at the conclusion of their appointment and no signs or symptoms of pneumothorax when they left their appointment. The physiotherapy record supported this.
The patient’s husband stated that, when interacting with the patient after the appointment, there were no symptoms of pneumothorax.
The patient woke the next day with difficulty breathing and worsening pain and was transported to hospital and treated for pneumothorax.
The patient’s husband contacted the clinic, told them of the adverse event, and cancelled any upcoming appointments.
The physiotherapist made two attempts to contact the patient on this day and did connect with the patient’s husband. The physiotherapist apologized, was empathetic, and offered to visit the patient in hospital or at home once the patient was discharged. The patient’s husband declined these offers and asked to be left alone.
The physiotherapist made two subsequent attempts to contact the patient for an update on their condition the following week.
Decision
The physiotherapist described a robust written and oral consent process. The patient disputed the oral consent discussion but did admit to signing a consent form that described pneumothorax as a possible adverse event with dry needling.
The physiotherapist described appropriate dry needling techniques for the following muscles that were dry needled and carry an identified risk of pneumothorax: infraspinatus, teres major, and latissimus dorsi.
The physiotherapist failed to identify that teres major and latissimus dorsi carry an identified risk of pneumothorax and was advised to reflect on this error and to ensure that they are notifying patients of this special risk when needling these muscles.
There was limited evidence to support or refute whether the patient understood what the medical term pneumothorax meant. The Complaints Director recommended that the physiotherapist consider using terms other than pneumothorax when discussing possible injury to the lung.
Given the number of interventions utilized with the patient in their first physiotherapy session, and given when the education and consent discussions surrounding dry needling as an intervention occurred in the sequence of events, the Complaints Director also recommended that the physiotherapist consider the timing of education about possible adverse events and consider reviewing these with patients at the conclusion of their appointments.
The physiotherapy record, while complete and reliable, provided minimal detail and context regarding the oral education provided to the patient and the consent discussions surrounding the physiotherapy interventions utilized. The Complaints Director recommended that the physiotherapist reflect on this practice.
The physiotherapist erred by failing to document the conversations and attempted conversations had with the patient and the patient’s husband. With no documentation of these interactions, there was little evidence to support the physiotherapist’s version of events. Thankfully, the patient and the physiotherapist were able to produce logs of the calls made to and from each other to add evidence to the attempts made and to the actual conversations.
Finally, the physiotherapist erred when they offered to visit the patient. This showed a lack of judgement and, despite efforts made to improve the therapeutic relationship with the patient, had the opposite effect. The physiotherapist was reminded to be attentive to maintaining appropriate professional boundaries and ensuring that they keep the therapeutic relationship positive and within the confines for physiotherapy services and professional expectations. The Complaints Director further recommend that the physiotherapist reflect on their management of this therapeutic relationship and examine the actions they took and the intent behind them.
Key Message
When considering adverse events with the use of needles in practice, whether it is acupuncture or dry needling, it is critical that physiotherapists consider not only the actual act of using needles in practice but all the education and management that occurs before and after the intervention. Dry needling may be performed perfectly, and an adverse event could still occur. The use of needles in practice is about much more than the act of inserting and removing the needle.
Consider the following:
- How much and in what manner have you provided information regarding benefits, risks, special risks, and how to manage any adverse events?
- Given adverse event symptoms often present after the fact, how can patients reach you, particularly after hours, if they are experiencing an adverse event? What have you told them about accessing 811, urgent care, or emergency services? How was this information delivered? Is it easily accessed in case of emergency?
- What have you documented regarding your education and consent processes? Will it support your version of events if a conduct case is opened?
- If an adverse event like increased symptoms or pneumothorax happens, what steps will you take to address this and how will you manage the therapeutic relationship?
- When using needles in practice, are you considering how rapidly you are presenting it as an intervention option versus how much time a patient may need to process the benefits versus risks? Is there a significant risk for the patient delaying the use of needles as an intervention a day or two to give them time to consider their options?
Pneumothorax is a serious medical condition. Physiotherapists that use needles in practice must treat it as such.
Case 5: Professional Boundaries, Safe Transmission of Health Information, and the Importance of Timely Documentation
January 29
Allegation
An employer made a Section 57 complaint to the College after terminating a physiotherapist’s employment for conduct the employer deemed to be unprofessional.
The College investigated three allegations:
- The physiotherapist’s documentation and record keeping did not meet the acceptable standard of practice.
- The physiotherapist’s patient billing practices did not meet the acceptable standard of practice.
- The physiotherapist failed to meet the expectations of the Client Assessment, Diagnosis, Interventions (2017) Standard of Practice.
Investigation
The investigation focused on document reviews from the employer and the physiotherapist.
The investigation also interviewed two patients to determine what billing practices were utilized for the physiotherapy services they received from the physiotherapist.
Two physiotherapy support workers were interviewed to determine their involvement in the provision of physiotherapy services.
Decision
The evidence collected in the investigation supported referring the matter for a hearing tribunal. However, the Complaints Director was able to secure the employer and the physiotherapist’s agreement to proceed with a Facilitated Resolution.
Facilitated resolution results in a formal and binding agreement between the physiotherapist and the College. The terms of the agreement were similar to orders the College would seek if the matter was referred for a hearing and the physiotherapist was found guilty of unprofessional conduct.
The Complaints Director concluded that the evidence collected supported the following:
- The physiotherapist made entries that were not contemporaneous in the physiotherapy records reviewed in this matter.
- The physiotherapist’s practice of referencing a separate electronic medical record entry when relying on another electronic medical record for the majority of the records reviewed fell short of the intent of the Documentation and Record Keeping Standard of Practice.
- The physiotherapist emailed and texted patient identifying information in a non-secure fashion.
- The identity of the payer was falsified in the two patient records reviewed in this matter.
- The amount billed for physiotherapy services did not align with the data documented in the physiotherapy record for one patient on two dates.
- That an alternate billing / payment plan was in place for two patients. There was no evidence presented to suggest that this plan was offered to all patients or made public in any way.
- The physiotherapist billed for virtual services but documented for in-person services on two dates.
- Overall, the authenticity of the physiotherapy records reviewed in this case was in question due to the number of entries that were made or signed after the fact and that virtual services were invoiced on a date that the physiotherapist documented that in-person services were provided.
The physiotherapist agreed to review and reflect on several publications relating to Boundary Violations and Power Imbalances in physiotherapy practice, the College’s Privacy Guide for Alberta Physiotherapists, the College's Documentation Module, several Standards of Practice, and the Code of Ethical Conduct.
The physiotherapist also agreed to complete a professionalism and ethics course approved by the Complaints Director.
Key Message
The alternate billing and payment practice the physiotherapist chose to offer to the two patients in this matter is a form of preferential treated and increased the power imbalance between the physiotherapist and the patients and started the blurring of professional boundaries. The physiotherapist is the professional and has a responsibility to keep the therapeutic relationship positive and within the confines of physiotherapy services and professional expectations.
Regarding sending identifiable health information, physiotherapists must ensure this information is transmitted as securely as possible with consideration given to the risks of non-secured structures.
Finally, all physiotherapists are reminded that documentation must be contemporaneous and completed as soon as reasonably possible to promote client safety and effective clinical care.
