Performance and Professional Standards panel
Date of Hearing: 17 May 2013
Date of Decision: 20 May 2013
Health record - inadequate or inaccurate or misleading
The Board alleged that the physiotherapist had failed to maintain clear, accurate, and up to date health records essential for the continuing good care of their patients, and had behaved in way that constituted unsatisfactory professional performance.
It was also alleged that the practitioner’s patient records did not hold relevant details of clinical history, clinical findings, investigations, information given to patients or clients, medication and other management; and that the patient records therefore did not contain sufficient information to allow another physiotherapist to continue the management of the patient and to facilitate continuity of care. It was also alleged that the physiotherapist’s patient records were not made at the time of consultation or treatment events, or as soon as possible afterwards, and did not include a record of every patient consultation.
The panel found that the practitioner had engaged in unsatisfactory professional performance in relation to all allegations. This was so despite the panel finding that the record keeping systems at the practitioner’s clinic contributed to the practitioner’s failure to meet the record keeping obligations required by the Code.
The panel cautioned the practitioner.