Policy statement: Physical therapy records management: record keeping, storage, retrieval and disposal

Policy type

The World Confederation for Physical Therapy (WCPT) aims to improve the quality of global health service delivery 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 physical therapy practice and viewed as essential for the protection and care of service users. 1

Records provide valuable information that can be used to:

  • show evidence of informed consent
  • facilitate clinical decision making
  • demonstrate duty of care
  • improve services including safety and quality through clear communication of intervention/treatment rationale
  • facilitate a consistent approach to collaborative 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 select and provide the highest quality services appropriate for 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 advocates that member organisations should:

  • provide support to their members regarding record keeping, storage, retrieval and disposal and in particular the application of national/provincial/state legislation and standards
  • ensure professional accountability for the services provided by a physical therapist and for high quality service provision and patient/client management
  • ensure that their members implement procedures for the safe storage, retrieval and disposal of all records in all formats (including written, electronic and digital)
  • ensure that their members record, store, transmit and dispose of patient/client data taking into consideration the requirements for confidentiality
  • ensure that their members are aware that individuals have the right to receive information about themselves recorded in any of their records and that this information should be given in an easily understandable format that is accessible to the individual and sensitive to their needs
  • ensure that physical therapist professional entry level education and continuing professional development covers records management
    • advise their members of the WCPT guidelines for records management 2

Glossary

Duty of care — is a legal obligation to always act in the best interest of patients/clients/populations and to protect them from unnecessary risk of harm by not acting or failing to act in a way that results in harm. 3-5 The legal expectation is that the physical therapist will provide services consistent with their level of training, skill and competence.

Informed consent — is a decision to participate in examination/assessment, intervention/treatment or research, taken by a competent individual who has received the necessary information; who has adequately understood the information; and who, after considering the information, has arrived at a decision without having been subjected to coercion, undue influence or inducement, or intimidation. Informed consent is based on the principle that competent individuals are entitled to choose freely whether to participate in examination/assessment, intervention/treatment or research. Informed consent protects the individual's freedom of choice and respects the individual's autonomy. 6 In order to obtain the valid consent of patients for examination/assessment, intervention/treatment or participation in research, they must be informed of all potential and significant risks, benefits and likely outcomes of intervention/treatment, taking into account their age, emotional state and cognitive ability, to allow valid/informed consent to be given. 7, 8

 

Approval, review and related policy information
Date adopted:

Approved at the 17th General Meeting of WCPT in June 2011.

Revised and re-approved at the 18th General Meeting of WCPT in May 2015.
Date for review: 2019
Related WCPT Policies:

WCPT policy statements:

  • Quality services
  • Standards of physical therapy practice
  • Relationship with other health professionals
  • Support personnel for physical therapy practice
  • Description of physical therapy

WCPT guidelines:

  • Standards of physical therapy practice

Records Management: record keeping, storage, retrieval and disposal

References
  1. World Confederation for Physical Therapy. Policy statement: Standards of physical therapist practice. London, UK: WCPT; 2017. www.wcpt.org/policy/ps-standards (Access date 10th March 2017)
  2. World Confederation for Physical Therapy. WCPT guideline for records management: record keeping, storage, retrieval and disposal. London, UK: WCPT; 2011. www.wcpt.org/guidelines/records-management (Access date 22nd September 2011)
  3. Social Care Institute of Excellence. Common induction standard 5: Principles for implementing duty of care.: Social Care Institute of Excellence; 2014 [Available from: http://www.scie.org.uk/workforce/induction/standards/cis05_dutyofcare.asp.
  4. Middleton R, White P. What does the term ‘duty of care’ mean in practice? Frontline. 2012;18(21):31-2.
  5. Chartered Society of Physiotherapy. Information paper PD101: Duty of care. London, UK.; 2013. 
  6. Council for International Organizations of Medical Science. International Ethical Guidelines for Biomedical Research Involving Human Subjects. London, UK: CIOMS; 2002. http://cioms.ch/publications/layout_guide2002.pdf (Access date 10th March 2017)
  7. European Region of World Confederation for Physical Therapy. European Core Standards of Physiotherapy Practice. Brussels, Belgium: ER-WCPT; 2008. http://www.erwcpt.eu/physiotherapy_and_practice/tools_and_resources (Access date 10th March 2017)
  8. Chartered Society of Physiotherapy. Quality Assurance Standards for physiotherapy service delivery. London, UK.: CSP; 2013. http://www.csp.org.uk/publications/quality-assurance-standards (Access date 3rd October 2016)

 

© World Confederation for Physical Therapy 2017