Medical Documentation in Physiotherapy - What's Mandatory

As a physiotherapist, you don't just perform treatments. You also keep medical documentation -- and that's a legal requirement, not an option. Every document must be kept in accordance with the Minister of Health's Regulation of 6 April 2020 on medical documentation (Journal of Laws 2020, No. 62, item 376), and since 1 January 2026 an amended Ministry of Health Regulation of 19 December 2025 has been in force (Journal of Laws 2025, No. [number]).

In this article we'll explain exactly which documents you need to keep, what to write in them, how to store them, and what happens if you don't.

The obligation to keep medical documentation

The legal basis is clear. Art. 23 of the Medical Activity Act of 15 April 2011 states directly: *"Medical activity is conducted on the basis of medical documentation."* And the Ministry of Health Regulation of 6 April 2020 specifies in detail what this means in practice.

The documentation obligation applies to every patient, regardless of whether they:

• Pay out of pocket or through the National Health Fund (NFZ)
• Come for a one-off consultation or a course of therapy
• Are an individual patient or part of a group session

Documentation isn't bureaucracy "for the authorities" -- it's your protection against patient complaints, proof that you did your job professionally, and the basis for settling accounts with an insurer or the NFZ.

Types of documentation you must keep

According to the 2020 Ministry of Health Regulation, a physiotherapist must keep four types of documents:

1. Patient record (individual medical documentation)

This is the main document, in which you record the patient's history. The patient record must contain:

• Personal details: name, surname, PESEL, date of birth, home address
• Patient history: previous conditions, operations, allergies, medications taken
• Reason for seeking you out: what the patient complains of -- pain, movement limitations
• Initial examination: your description of the patient's functional status (range of motion, muscle strength, tenderness)
• Physiotherapy diagnosis: what you found (e.g. "restricted shoulder range of motion, rotator cuff weakness")
• Treatment plan: which treatments, how many sessions, what goal
• Referral number (if the patient came with a doctor's referral)

You open a patient record before the first treatment and keep it throughout the therapy. The format can be paper or electronic (both are permitted from 2026).

[SP] Example -- Solo practice:
Mrs Zofia comes to your practice with knee pain after a fracture. You open a patient record for her, enter her details from her insurance card, ask about previous health problems (her mother may have had osteoporosis), and record your interview and initial examination (e.g. "tenderness in the front of the knee, bruising extending from the knee to mid-thigh"). This is the first entry in the patient record.

[GR] Example -- Group practice:
Two physiotherapists work at your practice. Patient Marek comes to you for his first visit, but has his second visit with a colleague. Marek's patient record stays at the practice (shared) -- you enter your notes from the first session, your colleague adds theirs from the second. All the therapists see the patient's full history.

2. Treatment plan (individualized treatment plan)

This document plans the course of therapy. It must contain:

• Therapy goal: what you want to achieve (e.g. "restore full range of motion of the shoulder girdle," "reduce pain from 8/10 to 3/10")
• Number of planned sessions: how many times the patient should attend (e.g. 10 sessions over 5 weeks)
• Types of treatments: which procedures will be used (e.g. "soft tissue massage, stretching, rotator cuff strengthening")
• Frequency: how many times per week
• Duration of a single session: how many minutes
• Notes: what the patient should do at home (exercises, movement, what to avoid)

The treatment plan is agreed with the patient -- they should understand it and give their consent. For patients unable to sign independently, a legal guardian signs.

3. Treatment log (treatment documentation)

This is a detailed description of every session you carry out. For each treatment you record:

• Date and time of the treatment
• Description of the procedure: exactly what actions you performed (e.g. "popliteal fascia massage for 15 minutes, quadriceps strengthening exercises for 10 minutes, isometric stretching")
• Parameters (where applicable): treatment duration, intensity (e.g. power in electrotherapy, temperature if thermotherapy)
• Patient's response: how the patient reacted (whether there was pain, whether they feel relief, whether there are results)
• Notes: anything unusual (patient didn't show up, patient's pain flared up during the session, we stopped the session due to their health condition)
• Therapist's signature: who carried out the treatment

The treatment log is essentially a series of notes, one entry per session. This is the hardest to keep consistently, but also the most important for your defence in a dispute with a patient or an insurer.

[SP] Example -- Solo practice:
Mrs Zofia comes to you for her second session (a week after the first). You write:

Date: 8 April 2026, 10:00-10:45
Procedures:
- Soft tissue massage around the knee, 15 min
- Quadriceps strengthening exercises, 10 min
- Isometric stretching, 8 min

Response: The patient reports a reduction in pain from 7/10 to 5/10. No new bruising. Knee range of motion increased by 5 degrees.

You enter this in the patient's treatment log.

[GR] Example -- Group practice:
Marek has a session with you on Monday, and with your colleague on Wednesday. Each of you enters your session into the same patient log (now electronic in most practices). After two weeks the patient can see the entire treatment path from both therapists.

4. Informed consent form for treatment

This is a legal document in which the patient gives consent to the procedures and confirms they understand the treatments and their risks. It must contain:

• Description of the treatment: exactly what you'll do
• Potential risks: what complications might occur (e.g. temporary increase in pain, bruising, a burning sensation)
• Benefits: what the patient can achieve
• Alternatives: whether there are other options (e.g. physical therapy vs. home exercises)
• Confirmation of understanding: the patient confirms they understand everything
• Signature and date: the patient signs, and you sign too as a witness

This document is mandatory especially for invasive treatments (like dry needling or injections), but it's good practice to have it for every treatment.

Changes from 2026 -- the new Ministry of Health Regulation

Since 1 January 2026 a new Ministry of Health Regulation of 19 December 2025 has been in force, introducing several changes:

1. Electronic documentation has become equivalent to paper documentation -- you can keep all documentation electronically, provided the system has appropriate security (encryption, backup)

1. Electronic signature (e-signature) -- since 2026 you can sign documents electronically (an advanced electronic signature, a qualified signature), which speeds up work in practices

1. Delayed documentation -- you don't have to log every note the second after a treatment, but you must do it within 24 hours of the procedure

1. Documentation of deceased patients -- the retention period has changed: instead of 20 years for everyone, documentation for a patient who died must now be kept for 30 years from the date of death (previously 20 years from the last entry)

1. Patient access to documentation -- the patient has the right to access their documentation; you can provide this through an electronic portal or paper copies

How to keep documentation: paper vs. electronic

Since 2026 both systems are permitted. You can choose:

Paper documentation

Pros:

• Simple system, no fear of IT threats
• The patient always sees the record in the practice
• No investment in software required

Cons:

• Hard to search (if you have 200 patients, finding a record takes time)
• Easy to lose a document
• Hard to send to an insurer (you have to scan it)
• Less secure against damp, fire, theft

Electronic documentation

Pros:

• Fast searching
• Automatic backup (if the system has it)
• Easier to send to an insurer
• More professional

Cons:

• Requires software (sometimes paid)
• Requires training
• Licence/subscription costs
• Risk: if your computer fails, you lose data (unless you back up)

Recommendation: If you work solo and have up to 50 patients -- paper may be enough. If you have a group practice or 100+ patients a year -- it's worth investing in an electronic system.

What every document must contain

Regardless of the format (paper or electronic), every medical document must have:

1. Patient identification details

• Name, surname, date of birth
• PESEL (not always mandatory, but recommended for security)
• Insurance number (if an NFZ patient)
• Phone number and email address (for contact)

2. Medical history

• Previous conditions
• Operations, procedures
• Allergies (to medications, substances)
• Current medications (may affect therapy)
• Past injuries and rehabilitation

3. Diagnosis always based on examination

• You may not write "fibromyalgia" based solely on the patient's words
• As a physiotherapist you enter your own physiotherapy diagnosis (e.g. "restricted range of motion of the shoulder joint, increased subscapularis muscle tension, external rotator weakness")
• This diagnosis should be the result of a clinical examination (tests, measurements)

4. Compliance with regulations

• You sign (or e-sign) every document
• Every document is dated
• You may not edit documents retroactively without marking it as a correction (e.g. "Correction dated 15.04.2026 -- treatment description changed based on new information from the patient")

Storing documentation -- how long and where

This is very important, because the sanitary inspectorate or the NFZ can ask you for documentation at any time. Here are the storage rules from 2026:

Living patient

• Minimum 20 years from the last entry in the patient record
• If a patient was with you in 2020, you must keep the record until at least 2040

Deceased patient

• 30 years from the date of death (a change from 2026, previously it was 20 years)
• If a patient died in 2026, you must keep the record until 2056

Minor patient

• 22 years from the last entry, but not less than until the child turns 18
• If a child's last entry was at age 15, you must keep the record until the child turns 22

Where to store it

• At the practice: in a cabinet/drawer, locked (protection against unauthorised access)
• Electronically: on a password-protected server, with backup
• Archive: if you have a lot of old documents, you can move them to a paper archive (e.g. in a basement), but they must be catalogued and available in case of inspection

Procedure for giving patients access to their documentation

A patient has a right to access their documentation. You need to know how to handle this. Since 2026 the procedure is:

In person

1. The patient asks you for access to their record
2. You allow them to read the documentation at the practice (they may read it, but may not photograph it without your consent)
3. If the patient wants a copy -- you make a scan or printout
4. The patient pays for the copy: from 0.10 PLN per A4 page (standard rate)

Through a representative

• If the patient sends a representative (another person), you require a certificate from the patient authorising that person
• If the patient is an adult but legally incapacitated, their guardian has access

Patient abroad or visually impaired

• If the patient asks you to send the documentation electronically (email) -- you must ensure it's a secure transmission (e.g. an encrypted PDF)
• If the patient is blind, the documentation must be available in a format read aloud (audiobook) or in Braille (if the patient wants this)

Frequently asked questions

Question 1: Do I have to keep paper documentation if I work solo?

Answer: No, you can work electronically (equally valid since 2026). However, if you use an electronic system, you must have:

• Documentation backup (at least once a month)
• Data encryption (so patient data can't be accessed if someone breaks into your computer)
• A procedure for what to do if your equipment fails

If you can't guarantee this -- it's better to keep paper documentation.

Question 2: Can I write something rough in the patient record and fix it later?

Answer: You may not edit past entries without marking it. If you made a mistake, you must:

1. Write after the incorrect entry: "Correction dated [date] -- changed X to Y, reason for correction: [justification]"
2. Sign the correction

An electronic system should track versions (what it was before the correction, what after). Paper system: cross out the error with a line and write "Error" next to it.

Question 3: What happens if I don't keep documentation?

Answer: The consequences are serious:

• Professional liability before KIF: missing medical records is a breach of professional duties that can lead to disciplinary proceedings before the National Chamber of Physiotherapists
• Removal from the RPWDL: if you repeatedly fail to keep documentation, you may be struck off as a practitioner
• Inability to settle with the NFZ: the NFZ won't pay you for treatments without documentation
• Civil liability: if a patient sues you for poor work and you have no documentation, you'll face a serious evidentiary problem -- the burden is on you to show the treatment was proper
• NFZ sanctions: under an NFZ contract, missing documentation can trigger a contractual penalty or contract termination during an inspection

Keeping documentation isn't bureaucracy -- it's your protection.

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Related articles:
- How to correctly keep a patient record in physiotherapy
- GDPR in a physiotherapy practice -- a practical guide
- Sanitary inspectorate inspection at a physiotherapy practice -- what they check