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Good Practice: Risk and Expectations Regarding Documentation

As a clinician who continues to practice, I can recognize that completing comprehensive charting in a timely manner can be a challenge to accomplish. However, I also recognize that although meeting the expectations around documentation can be challenging, the potential risks to the patient and myself as a physiotherapist should be reason enough to make it a priority.

In preparing this article, I consulted with the conduct team to get their perspective on documentation by physiotherapists. They noted that often complaints brought forward to investigations involve some sort of issue with a physiotherapist’s quality of documentation.

Since physiotherapists continue to raise questions and concerns regarding documentation and with the high rate of issues found in conduct in mind, the College of Physiotherapists of Alberta helped build an eLearning Module entitled, “The Write Stuff”, to address those questions and concerns.

This article will cover:
  1. Lessons learned from past conduct findings and the link to poor documentation
  2. Common questions regarding documentation and the College’s expectations
  3. An overview of “The Write Stuff” eLearning module
  4. How this is all connected back to your responsibilities as a physiotherapist
What Can We Learn from Previous Conduct Findings?

You can take your own journey down previous conduct findings here by looking at Disciplinary Decisions and even at the Notices of Upcoming Hearings. If you do take this journey, you will find a history of issues related to documentation from both public and private settings. Two notable findings to focus on with documentation are a physiotherapist failing to document and documentation of poor quality.

Failing to Document

This is not forgetting a single chart note out of hundreds of chart notes; we are talking about a complete lack of documentation. There have been complaints brought to the College where investigators have found instances in which there were chart notes completed less than 50% of the time. There have also been instances where there was no documentation of the assessment, treatment, education, or any other part of the physiotherapy services delivered. The only proof that the patient attended the clinic was the billing record.

Poor Quality

This is a much more common issue. While reviewing charts related to a complaint, the conduct team has noted “as previous” or “continue” in chart notes. Neither of these notes meets the expectations set out in the Standards of Practice. Having multiple “as previous” notes in a row demonstrates a larger disregard for documentation. This is also an issue within EMRs where you can copy and paste or use shortcuts for phrases that don’t accurately reflect what occurred in the patient interaction.

In these instances, did the patient report no changes? Did you ask them any questions regarding their injury? Was there any assessment related to their injury or reason for seeking physiotherapy? The treatment plan could be to repeat the same set of exercises or provide dry needling to the same points, but there must be more to the overall patient interaction. The documentation you provide that describes the interactions with the patient must be in sufficient detail so that another physiotherapist could walk in and understand what treatments you were providing, the reasoning behind those treatments, and whether they were effective.

What Can We Learn from Common Practice Advice Questions Regarding Documentation?

Now that we have looked at past conduct findings there are several common practice advice questions related to documentation that should be addressed.

1. How do I chart conversations with or about patients?

You must document the nature of the conversations you have regarding any of your patients. Some patients have others involved in their care (doctors, case managers, massage therapists, family members, etc.) and if you speak to any of them regarding your patient you should document that conversation. You don’t need to transcribe the exact conversation, but it should be clear what was discussed and the specific information or advice you provided. This is not documenting your discussion on the rugby World Cup or how their kid is doing in school- just the stuff related to the patient’s care.

This is adequate:

Phone conversation with Dr. Abbud. Discussed Mr. Murphy’s poor sensation in bilateral lower extremities. Voiced concern regarding the changes as testing did not indicate any MSK pathology. Discussed testing for circulatory impairment or peripheral neuropathy. Will continue to follow Mr. Murphy as Dr. Abbud coordinates further testing.

Or

Patient called today to discuss increased soreness after dry needling. Reviewed the potential risks related to areas treated and discussed the patient’s symptoms. Patient has no shortness of breath or chest pains but is achy through area of thoracic spine that was needled. Advised patient to apply heat pack for 10’ at a time every few hours and if symptoms worsen to go to the ER. Sensation testing completed in initial assessment but advised of risks associated with applying microwavable heat packs and that burns can commonly occur. Follow-up scheduled in 2 days, will reassess then.

This is not adequate.

(blank space because they didn’t chart it)

Or

Patient called RE: soreness post-treatment. Told to use heat. Will see next session for re-assessment.

If you failed to chart at all then you have absolutely nothing to indicate you did anything about Mr. Murphy’s bilateral lower leg symptoms. Or as in the other example, if your patient followed instructions to use heat but burnt themselves there would be no documentation that you reviewed the risks and advised them of how to use heat appropriately and for how long. Or if they did have a pneumothorax there would be no indication you asked any questions regarding their symptoms. Failing to document these discussions puts the physiotherapist at risk if the patient made a complaint or filed a civil claim due to harm they experienced from following your advice. This also provides an incomplete picture for other health professionals involved in the patient’s care.

2. What about texting or emailing patients?

Any electronic communication should be included in the patient’s chart record. Most EMRs can do this easily by inputting the communication directly into the patient's file or treatment notes. Printing out screenshots of a text exchange or printing off emails and slipping them into the paper record also works and fulfills performance expectations around documentation.

3. Could documentation solve the “they said/you said” debate?

One of my earliest mentors told me a story about a patient they had treated who was injured and on long-term disability. During rehabilitation, the patient phoned the physiotherapist and expressed a desire to get back to riding horses with his family as they were heading to the family farm for the weekend. The physiotherapist said no, due to their injury they should avoid it, but the patient ignored the physiotherapist’s advice and went riding. Unfortunately, the patient ended up re-injuring themselves and their disability insurer questioned the re-injury. There was a sudden dramatic turn in the therapeutic relationship as issues with the funder arose. The patient had claimed that they had clearance from the PT. The physiotherapist managed to resolve the issues related to themselves and their actions because they had documented their patient education and details of the conversation. When the physiotherapist was asked to provide their chart notes all the details were in there. If the physiotherapist had failed to document the conversation, they could also have been involved in the battle between the patient and the funder.

“The Write Stuff” eLearning Module

Let’s turn to the eLearning Module and an overview of the 5 aspects of documentation it covers.

1. Contemporaneous

The documentation module begins with a scenario. Kai is a physiotherapist who gets sick towards the end of his workday. He heads home but hasn’t charted on a patient, thinking he will be back tomorrow to take care of it. Unfortunately, his illness persists and there is a patient incident the next day due to his lack of charting on his patient’s change in condition.

The module goes into much more depth on the scenario and how the incident resulted, but one of the main things it points to is the concept of charting contemporaneously to avoid these types of situations.

Definition – Contemporaneous means occurring or originating during the same time period. In the physiotherapy context, contemporaneous is determined by the practice context and other expected or predictable uses of the record. Documentation that does not occur during the same time period poses a risk to the client and is generally seen to be less accurate and more likely to be questioned.

You will see “contemporaneous” in the Standards of Practice and the eLearning Module. The longer the period of time that exists between your patient interaction and when you record that interaction results in a higher risk of omitting or forgetting details of the clinical care provided. Furthermore, there are potential questions of its accuracy in the course of an investigation.

Many questions and concerns around documentation are regarding timelines for charting. Some physiotherapists ask if it is acceptable to chart at the end of the day or the end of the week depending on the practice setting. As the eLearning Module points out, charting at the end of the day could be acceptable depending on the practice setting and the potential risks involved. In a busier practice, it is important to take time during your patient interaction to chart what you have done. Ideally, setting aside 5’ at the end of every treatment session to chart would be best practice. Physiotherapists in both public and private settings are busy and can carry hectic, stressful caseloads that they must manage. While workload and scheduling can contribute to documentation challenges, it cannot be an excuse for not documenting an assessment, treatment, or discussion.

What’s needed, in some of these cases, is a culture shift from seeing documentation as a bother, to seeing it as an essential element of client care.

What’s needed, in some of these cases, is a culture shift from seeing documentation as a bother, to seeing it as an essential element of client care.

Part of the management and part of your interaction with the patient includes charting, and physiotherapists should view it as part of the treatment session. If your sessions are booked for 60 minutes, then 55 of those minutes can be directed to one-on-one patient care with the remaining 5 going to charting. If you are booking patients every 20 minutes the same expectations around charting apply.

If your practice setting doesn’t allow sufficient time to chart, then it is time to look at the model of care in place and talk with management about making time in your sessions to chart to meet your professional expectations. Sitting down at the end of the day to chart the 25 patients you saw creates its own challenges. You want to head home and see your family or destress by going for a walk but here you sit, still at work looking at a real or virtual stack of files to go through. Rushing to get through your charting, trying to recall details of patients, etc. can all lead to problems.

2. Comprehensive

This relates to the previous discussion about the quality of charting and the failure to document conversations that occur outside of the scheduled treatment time with a patient. Charting must include the details of professional interactions for many different reasons. Ensuring patient safety and quality of care is paramount to good practice. Protecting yourself from a complaint is another important reason to take the time to chart thoroughly. As we saw in the example of the patient horseback riding or the complaints mentioned at the beginning of the article, there are good reasons to spend time to chart with sufficient detail.

3. Informed Consent

Checkboxes are common in EMRs and are attractive as they can facilitate speed in charting. However, the mere act of checking a box does not mean that consent was obtained, and a checkbox alone does not reflect that informed consent was obtained. The issue is that a checked box says nothing about the conversation around consent. There is no chance to record any details regarding the consent process.

Did you talk about risks and benefits? Were there any questions regarding the proposed treatment?

Riskier activities should have a more thorough consent process and related documentation, a check box generally wouldn’t meet that requirement. Gaining ongoing informed consent is an obvious must, but documenting consent also must be done correctly to demonstrate that informed consent was obtained. My experience in Practice Advice and discussion with Conduct is that consent is not usually an issue until it is. When it is an issue, such as when a patient reports that they did not consent to something, it becomes a really big issue, so documenting consent well is a big necessity.

4. Organization

I don’t think it is much of a surprise to any physiotherapist that a chart should follow some organizational format. A well-organized chart note allows you and other practitioners to easily find key information regarding the patient’s history, injury, assessment, and treatment. SOAP and DARP are two common formats often used in Canadian practice and help to organize content in a chronological order that makes sense. EMRs now almost always contain templates for you to use that will keep your charts organized and allow you to follow a structured flow in your documentation.

5. Support Workers

Physiotherapists are ultimately responsible for the care of the client, but tasks often get assigned to support workers in the practice setting. When it comes to documentation and support workers, the documentation must show who provided care. If support workers are providing care, consent must be obtained from the patient and their consent must be documented. In many settings where the support worker is providing care, the support worker would be the one to document the physiotherapy tasks they completed, and the physiotherapist must ensure that the documentation completed by the support worker is consistent with the expectations found in the Standard of Practice – Documentation, as is the case for other aspects of physiotherapy services assigned to physiotherapist support workers.

In summary, it is important to highlight that documentation issues are a consistent problem in the complaints process and conduct findings. Documentation is also the source of many practice advice calls and persistent questions among registrants. Good documentation should be comprehensive, well organized, and done in a timely manner that is consistent with the Standards of Practice. Check out “The Write Stuff”, the College’s new eLearning module on documentation as it addresses common questions you need answered when it comes to good documentation. If you still have questions regarding documentation, please contact the practice advice team at the College.

[email protected] or 780-702-539

Good documentation should be comprehensive, well organized, and done in a timely manner that is consistent with the Standards of Practice.

Page updated: 31/10/2023