An employer submitted a complaint of unprofessional conduct to the College after discovering that much of an employee’s patient documentation was absent or incomplete. Approximately half of the patient visits, over one hundred attendances, were reportedly undocumented. The employer stated that the issue was being dealt with internally but decided to report the findings to CPTA due to the significant number of missing chart notes.
An investigation into the complaint was initiated pursuant to the s. 55(2)(d) of the Health Professions Act.
Allegation: Failure to meet CPTA’s Standard of Practice regarding Documentation and Record Keeping
The physiotherapist fully acknowledged that their record keeping for a period of time was subpar and required improvement. They disclosed that significant mental and physical health concerns were a contributing factor to not meeting the Documentation and Record Keeping Standard; however, the physiotherapist had not fully disclosed this to their employer at the time. The physiotherapist expressed a willingness to work with the employer to meet the required documentation standards. A personal learning plan was included in the member’s response to the allegation. The employer was committed to the learning plan as well. No further investigation was undertaken.
Based on a review of the preliminary evidence collected, the Complaints Director determined there was sufficient evidence of unprofessional conduct that the matter could be referred for a hearing. However, since the employer (the complainant) and the physiotherapist agreed to work together to resolve the documentation issues, the Complaints Director decided to utilize s.55(2) (a.1) of the Health Professions Act to resolve the complaint by way of Facilitated Resolution.
The physiotherapist entered into an agreement with the Complaints Director undertaking to:
- Review the Code of Ethical Conduct
- Review the Documentation and Record Keeping Standard
- Complete an e-learning module on medical documentation
- Review the Employee Assistance Program (EAP) Services offered through the employer
- Undergo three chart audits over 18 months at their cost
The physiotherapist was advised that if they failed to comply with the undertakings, or the Complaints Director determined that the results of one or more of the audits were unsatisfactory and the issues were not likely to be remediated during the subsequent audits, the Complaints Director may undertake either or both of the following:
- Refer the original complaint to a hearing
- Treat the member’s non-compliance as information for a new complaint under s. 56 of the HPA
Each condition was placed on the member’s practice permit and available on the public registry.
The physiotherapist fully completed all the terms of the agreement. All conditions were removed from the physiotherapist’s practice permit. The complaint file was closed.