Recognizing the importance of clear, plain language records keeping, the College of Physiotherapists of Ontario has updated their Record Keeping Standard. As of November 1, 2017, physiotherapists practicing in Ontario are required to adhere to revised standards. Below we offer a quick summary of the updates, but as always we recommend you download their official document, here.
As required by College of Physiotherapists of Ontario (the College), physiotherapists are still required to keep and maintain clinical records for each of their patients. The college requires that all records (including patient notes) be well organized, understandable and accurate.
Well Organized Patient Health Records
The new college updates specifically state that patient records be well organized. Meaning, notes must include the name of the care provider and/or the person that made the entry. Also, the College requires every entry be dated. If you like to keep your chart notes open and finish them all at once, then these updates require you to include both the date the note was created and the date the entry was made.
Legible, Easy to Read & Understandable Notes
As the update is to help ensure notes can be shared amongst healthcare providers, the College requires notes be readable. This is easily attained by using an electronic charting software. They also require that specialized terms and other short forms be explained or readily understandable by anyone involved in the patient’s care.
Timely and Accurate Health Records
The College requires physiotherapists to enter information within a reasonable amount of time to ensure the information entered is both accurate and timely. Further, they require that records be permanent by ensuring data is not lost or deleted. Any changes to the file must keep the original content intact with new additions noted and dated.
New Requirements for Physiotherapy Clinical Records
Under this update, the clinical records of the physiotherapist must support the care they provide. Each patient clinical record must contain (when possible) objective data, evidence, and outcome measures.
The robust clinical record keeping of InnoCare Charting+ includes a significant objective findings section as well as outcome measure tracking.
Notes taken by physiotherapists in Ontario must include data that can be interpreted by other healthcare providers involved in the patient's care and (if needed) allow them to assume care of the patient or follow the treatment plan. As per this update, “[i]nformation that is relevant to a patient’s care includes, but is not limited to:
- unique identifiers for the patient and for all providers involved in that patient’s care
- information about the patient: demographic information, health, family, and social history, and patient-reported subjective data
- discussions with the patient to obtain ongoing consent to assessment, treatment, and involvement of other care providers
- care refusals
- the date of every patient encounter, including missed appointments
- results of tests, investigations, assessments, measures, and any reports received regarding the patient's care
- details about analysis, diagnosis, patient goals, treatment plan, and treatments performed
- progress notes, outcomes, re-assessments, and resulting changes to the treatment plan
- details about any care that has been assigned to another person, or care provided collaboratively with other health providers, including consultations and correspondence
- discussions and communications with the patient including instructions, recommendations, and advice
- referrals and transfers of care to another health provider, and any reports sent regarding the patient’s care
- discharge summaries including reassessment findings, reason for discharge and other recommendations.”*
Stay on top of regulations and keep compliant records with InnoCare Software & InnoCare Charting+, learn more or start your 30-day trial by clicking here!
Staying on top of ever-changing regulatory college, provincial, and federal requirements can be a formidable task. If you’re an Ontario physiotherapist concerned about keeping compliant records, now is the time to consider choosing a software solution that takes care of that for you.
*For a comprehensive list of mandatory information and other requirements please visit the College of Physiotherapists of Ontario website here.