For the screening interview, you are required to select one patient record to conduct a self-audit record keeping checklist. Once you complete this checklist, you need to upload the completed checklist, NOT the patient file, to the PT Portal.

The purpose of conducting a self-audit of your record keeping is to help you identify areas of your record keeping that may benefit from improvement. It is okay to find a gap (or two) in your record keeping practices. Once you complete the checklist, review any items that you scored as No.

Take a moment to reflect on these items and comment on how you plan to correct them going forward.

No, you should not include the patient’s name but you should include enough detail to be able to locate the record, if the College’s Quality Assurance Committee requests it at a later date. 

Submit your completed Record Keeping Checklist by uploading it to the PT Portal.

Please upload the checklist as a jpeg, Word or pdf file.  

How to upload your Record Keeping Checklist: 

1. Log into the PT Portal
2. Click on the Practice Assessments tab 
3. Click on the Screening Interview link
4. Upload your Checklist in the document upload section  

If you are having difficulty uploading the file you can email it to qualityassurance@collegept.org or call the Quality Assurance Team for assistance at 416-591-3828 ext. 212 or 1-800-583-5885 ext. 212.

It is fine to use a multi-disciplinary record. You only need to review notes related to the physiotherapy care. 

After selecting a patient record to review, go through each item in the checklist and indicate YES for items that are present, NO for any missing items or NOT APPLICABLE (NA) if the listed item does not apply to the record you selected for review.

For any items you score as NA make a brief note why this item does not apply. For any items you score as NO make a note about what you plan to do to fix the problem.

The Record Keeping Checklist items are not part of the score that decides if you need to complete an on-site assessment but are considered part of your overall results.

Some PTs work in irregular hours or unique practice situations. All PTs selected for a screening interview must complete a review of one patient record using a checklist. If you work in a unique situation, you can select a record that best reflects your practice.  

Try to follow the advice in the instructional document for selecting a patient record to review. Alternatively, pick a patient record that best reflects your typical practice. For example, if you only assess patients in your current practice then select a patient record where you performed the assessment. You may not be able to score all items on the checklist. If checklist items do not apply to your practice or the record you choose to review, mark it as ‘Not Applicable’ and briefly state why. 

Also, do not review or score entries in the record that are completed by other team members — just yours.