The Case
The College received a complaint from a patient who attended a clinic for a massage therapy appointment. While she was waiting for her appointment to start, she asked her massage therapist if the clinic’s physiotherapist could take a look at an ankle injury that was troubling her. The massage therapist brought the patient over to the PT who agreed to see the patient.
The patient said the physiotherapist didn’t ask any questions about her medical history or note any pre-existing conditions during the examination. Following the examination of her ankle, the physiotherapist examined her back. During this time, he asked her to bend backward, which hyperextended her spine, and then he put his hands on her shoulders and pushed down toward the floor.
As the physiotherapist did not obtain previous medical history before treating the patient, he did not realize that she had a pre-existing condition in her spine, which caused her back pain in the past.
The examination of her back re-injured her lumbar spine and caused a flare up of her condition. According to the patient, the PT did not discuss treatment options with her first and therefore she did not consent to the lumbar assessment that was performed on her. She said she experienced back pain following treatment by the physiotherapist.
The PT said he agreed to see the patient and perform a brief, impromptu examination as a professional courtesy and did not ask her any questions about her medical history. He also said that she did not inform him of any pre-existing medical concerns. He stated that he performed a lumbar facet loading test to determine if the patient’s ankle pain was being referred from her back.
The physiotherapist did not make any notes about this examination in the patient’s clinical record.
The Standards
It’s the physiotherapist’s responsibility to ask appropriate questions in order to determine a patient’s relevant medical history. It’s not the patient’s responsibility to offer information about their health without being asked.
The physiotherapist indicated that he saw the patient at their request as a professional courtesy, however the PT still should have obtained relevant medical history. Taking a patient’s history is a core component of any physiotherapist-patient interaction and should always be performed regardless of the nature of the appointment.
Additionally, having a complete discussion with the patient about the course of treatment including projected risks and outcomes helps ensure that they fully understand and can consent to the treatment.
Had the PT asked questions about the patient’s medical history or explained the lumbar assessment he intended to perform, it’s possible that the patient would have raised concerns and the assessment/treatment would have been performed differently.
Lastly, the College’s Record Keeping Standard states that records should include “the date of every patient encounter, including missed appointments” as well as “results of tests, investigations, assessments, measures, and any reports received regarding the patient's care.”
The fact that a patient encounter is impromptu, unscheduled, or provided free of charge does not negate the importance of record keeping.
The Outcome
Sometimes doing a small, professional favour for someone can lead to more than what you bargained for. The PT was provided with advice and recommendations to help enhance his practice, including reviewing relevant College materials about consent and record keeping.
Essential Competency Profile for Physiotherapists in Canada
Consent
Record Keeping Standard