Draft Position Statement - Physical Therapy Record Keeping, Storage and Retrieval

Pending approval at the 17th General Meeting of WCPT in 2011.

This draft is provided to assist WCPT member organisations and individual physical therapists. If you have comments and feedback on the draft that you would like to be considered in the final edit prior to the general meeting please send them to Tracy Bury at tbury@wcpt.org.

Draft Position Statement: Physical Therapy Record Keeping, Storage and Retrieval

The World Confederation for Physical Therapy (WCPT) aims to improve the quality of global healthcare by encouraging high standards of physical therapy education and practice.  WCPT recognises the importance and legal requirement for high quality, accurate and comprehensive records. This is an expectation set out in agreed standards for the practice of physical therapy (WCPT, 2007).

Accurate and comprehensive record keeping is an essential part of professional accountability for the services provided by a physical therapist and is essential for high quality service provision and patient/client management. A physical therapy record consists of all information related to the provision of physical therapy services and is a legal requirement.. Failure to maintain accurate physical therapy records is deemed to be negligence. The record includes all information related to the management of individuals, including, but not limited to: written documents, computer files, audio tape, e-mails, faxes, video tapes, photographs and other electronic media. With physical therapists working in public health, health promotion and consultancy roles records should encompass assessments, such as environmental and occupational health, which may not be specific to individuals but situations; the outcomes of these and the resulting advice and actions require documentation.

Patient/client data has to be recorded, stored and transmitted with care, taking into consideration the requirements for confidentiality. All identifiable information about a patient's/client’s health status, diagnosis, prognosis and treatment and all other personal information must be kept confidential. Confidential information can only be disclosed if the patient/client gives their explicit consent or if it is expressly provided for in law. Information can be disclosed to other professionals for legitimate purposes if they are involved in the management of the patient/client.

Physical therapists should ensure that procedures are in place for the safe storage and retrieval of all records. These procedures should protect the information from loss, theft, unauthorised access or disclosure and tampering. They should also comply with local/national requirements for periods of storage and destruction processes. Only authorised personnel should have access to records.

Individuals have the right to receive information about themselves recorded in any of their records. This information should be given in an easily understandable format that is appropriate to the individual’s culture.

Records provide valuable information that can be used to:

• Show evidence of informed consent

• Facilitate clinical decision making

• Improve services including safety and quality of care through clear communication of intervention/treatment rationale

• Facilitate a consistent approach to team work, particularly in the context of multidisciplinary records

• Ensure continuity of service provision and management between different service providers

• Support other activities such as teaching, research, audit, quality assurance programmes and outcomes monitoring

• Demonstrate that physical therapists have selected and provided the highest quality care appropriate to their patients/clients

• Provide evidence in the event of litigation

• Provide a vital source of statistical and managerial information for the day to day running and future planning of physical therapy and health service provision

WCPT encourages its member organisations to provide support to their members in regard of record keeping, storage and retrieval and in particular the application of national legislation and standards.

An appendix to WCPT physical therapy record keeping, storage and retrieval is available.