Common Documentation Pitfalls in Kinesiology Practice

Guest blog post written by Xana Ouellette, a Registered Kinesiologist with a Bachelor of Human Kinetics (Movement Science) from the University of Windsor.

Documentation is yet another topic that is typically not included in undergraduate Kinesiology education, and is a crucial skill for Registered Kinesiologists in almost every practice setting. Since the inception of the College of Kinesiologists of Ontario in 2013 there have been six disciplinary hearings with a seventh scheduled for later in 2022. Three of these hearings were related to paperwork and documentation. Clearly, this is an area where Registered Kinesiologists need to be aware of their legal duties and ethical responsibilities. 

Consider the following scenarios of a Registered Kinesiologist in Clinical Practice: 

• You’ve worked a long day, started early, stayed late. You’ll wait until tomorrow to finish charting because you just can’t wait to leave the clinic. 
• You skip a note because the physiotherapist saw the client/patient right after you and they made a note about the session. 
• You have been seeing the same client/patient weekly for 10 months for fascial stretch therapy, the treatment is always the same, so you don’t create a SOAP note for this encounter. 
• You’re seeing a client/patient for shoulder pain, and they complain of pain in their pectoral on the same side. You do a brief assessment and decide the pain is non-cardiac. You don’t document the brief assessment in your note. 
• You apply k-tape to a client/patient’s back after their massage with another provider, and don’t make an encounter note for it. 

No one comes into work in the morning and says, ‘I’m going to do a bad job today.”

These things are small, they don’t seem like a big deal and bad habits develop. But in healthcare, these small slip-ups can lead to major disasters. 

Considering the actions of the Kinesiologist in the scenarios from above - as unlikely as these following outcomes might be, you should always be prepared for the worst. 

• You get abdominal pain overnight and end up in the hospital needing emergency surgery for your appendix. Those chart notes never get entered. 
• The physiotherapist didn’t chart well. Their note says “exercise interventions performed by Kinesiologist” and nothing more. 
• The client/patient’s lawyer reaches out to you to ask for your 10 months of chart notes to help support legal action. 
• The client/patient’s chest pain doesn’t subside, they attend the emergency department and evidence of a MI is seen. 
• The client/patient reacts to the k-tape and comes back to the clinic with a large, swollen, irritated patch of skin on their back.

Of course, in most cases, you’ll be fine. Complaints won’t be made to the College and your client/patient won’t retain a lawyer. But is it worth the risk? 

Your practice is only as good as your documentation. Remember, write it down (or type it out) every time. Explain why you did what you did and what you were thinking at the time of the appointment. If you talk to the client/patient later about their care, add notes from the phone call or a copy of the email into the chart.

Protect yourself for a long and great career. 

Xana Ouellette is a Registered Kinesiologist with a Bachelor of Human Kinetics (Movement Science) from the University of Windsor. She has worked in outpatient, long-term care, and community settings over her career and is passionate about educating and empowering Kinesiologists across Ontario. Xana can be found at https://www.kincarp.ca/ where she provides CPR/First Aid training as well as gym based Kinesiology services.

Professional link: https://www.kincarp.ca/
Instagram: @kincarp.ca