A PDF version of this Standard can be downloaded here.

Introduction

Health records are essential for the provision of quality health care services and protection of ngā kiritaki hauora by providing a record of assessment, treatment, management and communications between the physiotherapist, other health providers, and those supporting them.

Documenting and maintaining appropriate health records is important for the following reasons:

to ensure the safety of the individual receiving physiotherapy services
to provide a documented record of physiotherapy services given and the rationale
to provide a standardised way of communicating between physiotherapists and other health professionals
to support an accurate record of the continuity of care the individual received.
in the event of a dispute or investigation, health records provide vital information.

Definition

Health records: Health records include all forms of documentation containing health information and other specific information relevant to te kiritaki hauora interactions. Health records include information relating to an identifiable individual irrespective of the medium, i.e., electronic, web based, telehealth or paper based, made by physiotherapists.

In this Standard ‘health information’ has the same meaning as the definition of that expression in the Health (Retention of Health Information) Regulations 1996[1].

Ngā kiritaki hauora: Person(s) that uses health care services (patient, client, or consumer)

New Zealand law

Physiotherapists must be familiar with the law governing this area of practice including but not limited to the Health (Retention of Health Information) Regulations 1996 and the Health Information Privacy Code 2020.

1. Creation and content of health records

Physiotherapists must maintain clear and accurate individual-specific information records of all kiritaki hauora interactions.

Commentary: Clear accurate individual-specific records of all ngā kiritaki hauora interactions must be kept by physiotherapists. These interactions (both to and from kiritaki hauora) include, but are not limited to, information collected during assessments and face to face meetings and phone calls, all forms of messages, emails and telehealth.

This can also include when they do not attend, or if another person contacts the physiotherapist about the kiritaki hauora or on their behalf.

Recording of group sessions is not deemed to be a health record, however documenting of individual responses may be required. These then would be considered health records.

Health records must contain all pertinent information relevant to the context of the physiotherapy services being provided.

Commentary: The pertinent or relevant information which needs to be documented will differ depending on the setting or context in which the physiotherapist is working. Documentation needs to be sufficient for continuation of physiotherapy services, able to be understood by physiotherapists who may be continuing the service of the individual and to ensure the safety of the public is maintained.

Health records must be sufficient to ensure the safety and respectful interaction with kiritaki hauora when receiving physiotherapy services, and include, when and where appropriate, consideration and documentation of cultural needs and informed consent.

Key demographic data such as full name, NHI number (if available), date of birth, gender, ethnicity, contact details, and, where needed, the name of the General Practitioner should be included.

Physiotherapists must record all red flags, cautions and contraindications relevant to kiritaki hauora presentation and physiotherapy services being provided.

Commentary: It is expected that in all settings and contexts that relevant positive and negative findings for red flags, cautions and contraindications are documented. This allows for any decisions made to be reviewed later if required and may assist in identifying any changes to ngā kiritaki hauora health over time.

All oral and written informed consent must be clearly documented, dated, and include an explanation of any information provided. (See Informed Consent Standard)

Commentary: For further clarification of when oral versus written informed consent is required, please see the Informed Consent Standard

Health records must be easy to understand with good reasoning to allow other physiotherapists and health practitioners to be able to provide continued care.

If any of the information relevant to the physiotherapy services being provided cannot be obtained or completed, a noted reason for the unavailability of that information must be made in the health records.

Commentary: If information relevant to the physiotherapy services being provided cannot be collected for any reason this must be recorded to demonstrate that it has been considered. For example, refusal by ngā kiritaki hauora to disclose previous medical history may act to highlight that certain diagnoses cannot be ruled out and may be missed- document this in the health records.

Health records must be completed at the time or as soon as reasonably practicable after every interaction.

Reports (diagnostic procedures, letters, emails) and/or information on how to access these must be stored with the health records.

Commentary: Any reports, letters or additional information need to be able to be accessed easily by other health practitioners involved in the care. As an example, if reports or images cannot be accessed or viewed directly from the health records, a note needs to be included where to access.

Each interaction with ngā kiritaki hauora must be recorded as a unique entry in the health records.

Commentary: When documenting health records, where previous records are used to ‘copy and paste’ into or ‘auto-populate’ later records, care must be taken to ensure that the new record accurately reflects the unique aspects of that specific interaction.

Abbreviations used by the physiotherapist must be available as a list on request.

Alterations may be made to health records. These must be identifiable, dated, and initialled or signed by the person who made them with an explanation and/or addendum. Note: The earlier entry must not be changed or deleted.

Commentary: Alterations may be made to health records however these must be identifiable, dated, and initialled or signed (in writing or electronically) by the person who made them with an explanation and/or addendum. Efforts to obliterate original statements may give the appearance of covering up an error or mistake.

Physiotherapists supervising students must check and countersign all health records made by the physiotherapy student.

Commentary: As the responsible health practitioner, when supervising physiotherapy students, physiotherapists are required to ensure the Physiotherapy health records standard is being met. This includes checking and countersigning all records made by the student.

2. Physiotherapy Health Records and Privacy Law

Physiotherapists must be familiar with the law governing this area of practice including, but not limited to, the Health (Retention of Health Information) Regulations 1996 and the Health Information Privacy Code 2020.

Commentary:

The Code of Ethics and Professional Conduct (section 5.8) states that ‘Physiotherapists must have a full understanding of and comply with the laws and regulations that govern and impact on the practice of physiotherapy in New Zealand’.

With regard to matters relating to Health Records this includes the Health (Retention of Health Information) Regulations 1996 and the Health Information Privacy Code 2020

For all matters related to Privacy Law and how it relates to health records it is recommended that physiotherapists contact the Privacy Commissioner or seek legal advice. Areas may include but are not limited to:

collection of health information
access to and disclosure of health records by kiritaki hauora and organisations
carrying health records – paper based and digital e.g., on a laptop
transfer and sending of health records to other health professionals and organisations
storage, security, retention, and disposal of health records.

Additional Commentary:

In the event of a dispute or a complaint, the health record may be the key source of information about what was said and done in the physiotherapist- kiritaki hauora encounter, and a copy may be requested by disciplinary bodies. Therefore, it is imperative to maintain high quality records to record why decisions were made, whether consent was obtained and what intervention was undertaken, or what services were provided. Appropriate health records are important, both for the safety of kiritaki hauora and to safeguard the interests of the physiotherapist.