Record keeping is an essential part of providing care to patients. A high quality patient record demonstrates professional accountability, gives patients a clear chart of documented progress or setbacks, and ensures liability for all physiotherapy services delivered. But, what happens when a patient record is documented sporadically, haphazardly, or not at all? Where does that leave the patient? And where does that leave the physio?...especially when there are legal proceedings involved.
*The following story is based on an actual Ontario coroner's case*
In early 2010, 93 year-old Edna Michaels (not her real name) was admitted to a Long-Term Care home and was quickly assessed, identified and documented as being a fall risk by the LTC physiotherapist. The PT recommended mobility and exercise strategies for Michaels to be carried out by the nursing staff.
In January 2013, Michaels fell, fracturing her pubic rami and leaving her in great pain. After a brief hospital stay, Michaels returned to the LTC home and was reassessed by the physio who assigned a walking program for Michaels to be delivered by the PTA.
6 months later, she again fell. This time fracturing her hip and requiring surgery. After returning to the LTC home, she was reassessed by the PT who obtained documented consent from Michaels' family to re-institute the walking program. However, there was no documentation indicating whether or not any other physiotherapy was being provided, what was being provided, or by whom, despite clear recommendations from the orthopedic surgeon and the hospital physiotherapist.
Michaels steadily declined, sustained two more falls and ultimately died, but there were no further records or notes from the physiotherapist.
Michaels’ family says the lack of treatment and poor communication between the PT and other health care providers after Michaels’ release from hospital contributed to her ultimate demise. The family is suing, and with no patient records there is no proof on the PTs behalf to refute these claims, leaving the physio without a defense in a potentially career damaging wrongful death lawsuit.
*This case is also true and comes to us from our American neighbours*
Physiotherapist Anuradha Bhatt (not her real name) knew Jace wasn’t ready to weight bear as tolerated. Jace Seidel (not his real name) was the 10 year-old patient who came to her clinic in the spring of 2014 after surgery to repair his fractured left femur.
His orthopedic surgeon ordered weight bearing as tolerated for Jace’s recovery, however, Bhatt has extensive knowledge of bone healing and believes weight bearing as tolerated is premature in Jace’s road to rehabilitation, and calls the MD to express her concerns. The MD assures Bhatt that radiology exams reveal good bone healing and restates weight bearing as tolerated. Bhatt thoroughly records her concerns and her talk with the Doctor in the patient’s record.
Sadly, Bhatt’s fears were soon actualized when during therapy - doing active exercises against gravity in standing, Jace re-fractures his femur. Jace’s mother is livid, blames Bhatt, and files a lawsuit against her.
The court upheld the PTs position that it was not her responsibility to assess the status of bone healing or weight bearing status and that is was appropriate to rely on the MD.
The Judge was able to make this assessment based on the clear communication between the PT and the patient’s other health care provider – in this case the Doctor, and, PTs up-to-date and thoroughly detailed patient records.