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 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 of 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 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 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
  • encourage accurate and comprehensive record keeping as an essential requirement of 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
  • ensure that their members record, store, transmit and dispose of patient/client data taking into consideration the requirements for confidentiality
  • make their members 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]
  • that the electronic systems for record keeping and communication are functional and secure

Glossary

Informed consent— is a decision to participate in assessment, 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 assessment, treatment or research. Informed consent protects the individual's freedom of choice and respects the individual's autonomy. In order to obtain the valid consent of patients for assessment, treatment or participation in research, they must be informed of all potential and significant risks, benefits and likely outcomes of treatment, taking into account their age, emotional state and cognitive ability, to allow valid/informed consent to be given.[3] [4] [5]

 

Approval, review and related policy information
Date adopted: Approved at the 17th General Meeting of WCPT in June 2011.
Date for review: 2015
Related WCPT Policies:

WCPT policy statements:

WCPT guidelines:

References
  1. World Confederation for Physical Therapy. Policy Statement: Standards of physical therapy practice. London, UK: WCPT; 2011.  (Access date 22nd September 2011)
  2. World Confederation for Physical Therapy. WCPT guideline for records management: record keeping, storage, retrieval and disposal. London, UK: WCPT; 2009.  (Access date 22nd September 2011)
  3. The Chartered Society of Physiotherapy. Core standards of physiotherapy practice. London, UK: Chartered Society of Physiotherapy; 2005.  (Access date 22nd March 2010)
  4. European Region of World Confederation for Physical Therapy. European Core Standards of Physiotherapy Practice. Brussels, Belgium: ER-WCPT;2008.  (Access date 22nd March 2010)
  5. Council of International Organizations of Medical Science. Ethical Guidelines for Biomedical Research Involving Human Subjects. London, UK: CIOMS; 2008.  (Access date 23rd March 2010)
Bibliography
Publications from the Chartered Society of Physiotherapy (UK):