The Case

The College received a complaint from a patient about the practice of a physiotherapist. The patient attended an initial assessment with the PT and six follow-up appointments with a physiotherapist assistant (PTA).

The patient requested a copy of their patient record to send to their insurance provider. After receiving the record, the patient noticed that the invoices included the names of physiotherapists who were never involved in the patient’s care. The clinic sent an email to the patient apologizing for the mistake and offered to refund the fees for all the appointments.

As part of the investigation, it was discovered that the clinic billed personal training as physiotherapy services and used the registration numbers of physiotherapists who no longer worked at the clinic. The clinic provided prescheduled initial assessments by the physiotherapist and a PTA was assigned to follow the PT’s treatment plan and incorporate additional exercises if needed. However, there was no documentation in the patient record to support that the physiotherapist obtained informed consent from the patient about the PTA’s role in their treatment plan.

The physiotherapist said they obtained verbal consent from the patient to include the PTA in the patient’s care but acknowledged that consent was not documented in the chart. The PT also stated that the physiotherapist assistant was instructed to follow the treatment plan and document all the progress notes in an Excel spreadsheet. According to the physiotherapist, the PTA was told not to change a treatment plan without consulting the PT by phone or email. The physiotherapist couldn’t explain how the names and registration numbers of other physiotherapists were listed on the invoices because they didn’t manage their own billings.

The physiotherapist noted that they no longer worked at the clinic and had already reviewed resources on the College website related to fees, billings, and consent.

The Standards

The Record Keeping Standard states that all clinical records must support a physiotherapist’s rationale for the care they provide. Clinical records must also include objective data, evidence, and outcome measures. In this case, the patient record didn’t have any information about the patient’s past and present health status, details about the assessment, diagnosis and patient goals to support the proposed care plan.

The College’s Consent Resource states that physiotherapists must obtain a patient’s consent to involve others in the patient’s care, including PTAs. Although the PT said they obtained consent from the patient to include the PTA in their care plan, there was no evidence of this conversation in the patient record.

According to the Fees, Billings and Accounts Standard, a physiotherapist must have a written process for routinely reviewing fees, billings, or accounts to make sure they are accurate and reasonable. If a PT discovers errors, they must take reasonable steps to correct and document them. Although the physiotherapist didn’t manage their own billings, the PT was still responsible for ensuring that all billings submitted by the clinic using their name and registration number were accurate. The PT didn’t have a process in place to check the invoices and didn’t take steps to document or resolve the errors when they were discovered.

The Working with Physiotherapist Assistants Standard states that a PTA shouldn’t make changes to the established care plan on their own. In this case, there wasn’t any documented evidence to support that the PTA consulted with the PT before modifying the patient’s treatment plan.

The Outcome

The physiotherapist agreed to enter a voluntary practice enhancement program with a College-approved practice coach to better understand the requirements for record keeping, working with physiotherapist assistants, and fees and billings.

Record Keeping Standard

Fees, Billing and Accounts Standard

Working with Physiotherapist Assistants Standard

Consent Resource