Medical Documentation in Physiotherapy

As a physiotherapist, you don't just perform treatments. You also keep medical documentation, and that's a legal requirement, not an option. The details are set by the Minister of Health's Regulation of 6 April 2020 on the types, scope and templates of medical documentation and the manner of processing it (Journal of Laws 2020 item 666, consolidated text: Journal of Laws 2026 item 1391). Since 1 January 2026 it includes the changes from the regulation of 19 December 2025 (Journal of Laws 2025 item 1853).

In this article we explain which documents you keep in a professional practice, what the record contains, how long you store documentation and how you make it available.

The obligation to keep medical documentation

The basis is the Act of 6 November 2008 on Patients' Rights and the Patient Ombudsman. Article 24(1) obliges an entity providing healthcare services to keep, store and make available medical documentation and to ensure the protection of the data it contains. How the documentation should look is described in the regulation.

The Act does not differentiate this obligation by payer or type of visit. It applies to services provided to private patients and under the NFZ, to one-off consultations and courses of therapy. Medical documentation contains at least: the identification of the patient, the identification of the entity providing the services, a description of the patient's health condition or of the services provided to the patient, and the date of preparation (Article 25(1)).

Documentation isn't bureaucracy "for the authorities". It is your proof that you did your job professionally and the basis for explanations in case of a complaint or inspection.

Types of documentation in a professional practice

The regulation divides documentation into individual (about a specific patient) and collective, and individual into internal and external (§ 2). A physiotherapist providing services in a professional practice keeps, under § 62(1):

• internal documentation in the form of an individual physiotherapy care record,
• external documentation in the form of a certificate, ruling or physiotherapy opinion and other documents prepared at the request of the patient or other authorised entities.

An exception applies to a physiotherapist who practises solely in a healthcare facility under a contract with the healthcare entity. That person makes entries in the documentation kept by that entity (§ 62(2)). The regulation does not separately list a "treatment plan", "treatment log" or "consent form". The plan and the description of treatments fit within the record, and consent is covered separately below.

1. The individual physiotherapy care record

This is the main document. You create it when providing a service for the first time (§ 62(3)), and its scope is set out in § 49(4). The record contains:

• patient data: sequence number, name, PESEL (or identity document details), date and type of treatment (§ 49(3)); the Act additionally requires, among others, the date of birth, sex and address, and for a minor the details of the legal representative (Article 25(1)(1)),
• the diagnosis of the disease, health problem or injury, information on past and coexisting conditions and a description of functional status,
• data on the physiotherapy management and its performance, and a description of the health services provided,
• recommendations,
• information on rulings, opinions or certificates issued and on medical devices ordered by the physiotherapist,
• the date of the entry and the identification of the physiotherapist providing the service.

You attach a referral to the record where applicable (§ 49(5)). You enter the diagnosis according to the International Classification of Diseases and Health Problems and describe functional status with regard to the ICF classification (§ 7).

[SP] Example -- Solo practice:
Mrs Zofia comes to your practice with knee pain after a fracture. You create the record, enter her identification data, history of past and coexisting conditions and the initial examination (e.g. range of motion, muscle strength, tenderness), then the diagnosis and a description of the physiotherapy management. This is the first entry in the record.

[GR] Example -- Group practice:
Two physiotherapists work at your practice. Patient Marek has his first visit with you and his second with your colleague. Both therapists' entries go into the same record, and each entry carries the identification of the person who made it (§ 4(2)).

2. Treatment plan and description of treatments

The regulation requires the record to contain data on the physiotherapy management and its performance, a description of services provided and recommendations (§ 49(4)). In practice it is convenient to keep them as separate sections of the record. We suggest the plan contain the therapy goal, types of treatment, planned number and frequency of visits and recommendations for the patient, and the description of each visit the date, actions performed, treatment parameters, the patient's reaction and the therapist's identification. This is our suggested layout, not a template from the regulation.

[SP] Example -- Solo practice:
Mrs Zofia comes for her second visit a week after the first. You enter the date, the treatments used (soft-tissue massage, strengthening exercises, stretching), the patient's reaction (pain reduced from 7/10 to 5/10) and home recommendations.

3. External documentation

A certificate, ruling or physiotherapy opinion and other documents at the request of the patient or authorised entities are external documentation (§ 62(1)(2)). You record the issue of such a document in the record (§ 49(4)).

4. Patient consent to treatment

The documentation regulation does not impose a separate consent form on a physiotherapist. When and in what form you collect consent follows from other provisions that we did not check in this article. For a practical discussion see the article on patient consent to treatment in physiotherapy.

Changes from 2026

Since 1 January 2026 the regulation of 19 December 2025 has been in force, which changed, among others, § 7(1), § 9(2) (referrals) and § 10(1) (identification of the entity in the documentation). Referrals issued before that date remain valid, and until 30 June 2026 they could be issued on the previous terms. You will find the full list of the 2025-2026 amendments and a checklist for a practice in the article Medical Records Regulation for Clinics.

Form of documentation: electronic and paper

The rule is electronic form (§ 1(1)). Paper is allowed where a provision of the regulation says so or where organisational and technical conditions make electronic documentation impossible (§ 1(2)). You keep one document in one form (§ 1(3)). If you rely on the exception, record your reasons. We did not check how inspecting bodies assess this condition.

Electronic documentation. The system must, among other things, ensure the integrity of the content, identification of the person making an entry, information on the time of the entry, and the ability to print and export data (§ 1(6)). Securing documentation requires, among other things, risk assessment, documented access and storage procedures and software updates (§ 1(5)). Documentation is signed with a qualified electronic signature, a trusted signature, a personal signature or the mechanisms of the ZUS system, and internal documentation also with the system's internal mechanisms (§ 4(3)-(4)). The provision on signatures is not new in 2026. We describe choosing software in the article on choosing an EDM program.

Paper documentation. Pages are numbered and form a chronologically ordered whole (§ 6(1)), entries are legible and in chronological order (§ 4(1)), and the documentation carries a handwritten signature (§ 4(5)). Pros: a simple system and no software costs. Cons: harder to search, risk of destruction or loss, no automatic backup.

Rules for making entries

• Timing. An entry is made without delay after the health service is provided (§ 4(1)). The regulation gives no number of hours.
• Identification of the person. Entries and changes to entries carry the identification of the person making them: name, professional title, right-to-practise number if assigned, and signature (§ 4(2), § 10(3)).
• Correcting errors on paper. An entry in paper documentation must not be removed. An erroneous entry is struck through and an annotation added stating the reason for the error, with the date and identification of the person making the annotation (§ 4(6)). In an electronic system changes to entries must be identifiable (§ 1(6)). We describe details in the article how to correct an error in medical records.
• Diagnosis. You enter the diagnosis resulting from your own examination, according to the classification (§ 7(1)), not the patient's declaration alone.

Storing documentation: how long and where

The retention period follows from Article 29 of the Patients' Rights Act, not from the documentation regulation. As a rule it is 20 years counted from the end of the calendar year in which the last entry was made. Exceptions:

Documentation	Retention period
Death of the patient as a result of bodily injury or poisoning	30 years from the end of the year of death
Documentation of children up to the age of 2	22 years
Referrals for tests or doctor's orders	5 years from the end of the year the service was provided (2 years if the patient did not show up and did not collect the referral)
X-ray images stored outside the documentation	10 years from the end of the year the image was taken

After the period expires you destroy the documentation in a way that prevents identification of the patient (Article 29(2)). Internal documentation is stored by the entity that prepared it (§ 69(1) of the regulation). Storage must protect against destruction, damage, loss and access by unauthorised persons (§ 1(7)). For electronic documentation remember the GDPR requirements at a physiotherapy practice. We discuss archiving practice in the article on archiving medical records. Inspections that may ask for documentation are described in, among others, the article on what a Sanepid inspection checks.

Giving patients access to documentation

The entity makes documentation available to the patient, the patient's legal representative or a person authorised by the patient (Article 26(1)). Documentation is made available (Article 27(1)):

• for inspection at the place where services are provided, with the possibility of making notes or photographs,
• by preparing an extract, transcript, copy or printout,
• by handing over the original against a receipt, at the request of public authorities or courts or where delay could endanger the patient's life or health,
• by electronic means of communication and on an electronic data carrier.

The entity keeps a register of documentation made available (Article 27(4)), which we cover in the article on the register of medical records disclosures. For an extract, transcript, copy, printout or data carrier the entity may charge a fee, but not when documentation is made available to the patient or the patient's legal representative for the first time in the requested scope and manner (Article 28(1) and (2a)). The maximum fee for one page of a copy or printout may not exceed 0.00007 of the average wage in the previous quarter (Article 28(4)). A patient's request is described in the article on the request for access to medical records.

A printout is confirmed by an authorised person giving name, position and signature, and when paper is handed over a copy or full transcript stays behind (§ 70(2)-(3)). A refusal to make documentation available is given in electronic or paper form, always stating the reason (§ 71). We did not check the rules for access after a patient's death (Article 26(2)) or special formats for people with disabilities in this article.

Frequently asked questions

Do I have to keep paper documentation if I work solo?

No. The rule is electronic form (§ 1(1) of the regulation) and paper is the exception (§ 1(2)). If you keep documentation electronically, the system should ensure content integrity, identification of the person making an entry and the ability to print and export data (§ 1(6)), and you need documented security and access procedures (§ 1(5)). If you cannot meet this, check whether the exception in § 1(2) applies and record the justification.

Can I correct an entry in the patient record after the fact?

You cannot remove an entry from paper documentation. You strike through the erroneous entry and add an annotation with the reason for the error, the date and your identification (§ 4(6)). In an electronic system changes must be identifiable, with information on the person, scope and time of the change (§ 1(6)).

What happens if I don't keep documentation?

The Patients' Rights Act imposes the obligation to keep documentation (Article 24(1)), so its absence is a breach of that obligation. We did not check specific sanctions in this article (professional liability, consequences for the practice register, NFZ settlements or civil liability), so we do not give them. In practice, missing documentation makes it harder to show the treatment was proper when a patient makes a claim.

How long do I keep documentation?

As a rule 20 years from the end of the calendar year in which the last entry was made, with the exceptions in Article 29(1) of the Patients' Rights Act, for example 22 years for the documentation of children up to the age of 2.

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Legal status as of: 3 November 2026

Legal basis: Regulation of the Minister of Health of 6 April 2020 on the types, scope and templates of medical documentation and the manner of processing it (Journal of Laws 2020 item 666; consolidated text Journal of Laws 2026 item 1391), §§ 1, 2, 4, 6, 7, 10, 49, 62, 69-71; amending regulation of 19 December 2025 (Journal of Laws 2025 item 1853), §§ 1-4; Act of 6 November 2008 on Patients' Rights and the Patient Ombudsman (consolidated text Journal of Laws 2024 item 581), Articles 24-29; the changes in Journal of Laws 2026 item 26 (Article 28(2), ZUS powers) and item 791 (Article 26(5), Articles 30a and 30b) do not concern the provisions cited in the text. We did not check: the rules on patient consent to treatment, the Act on the profession of physiotherapist, sanctions for lacking documentation, the rules for access after a patient's death, inspection practice, or the current average wage amount needed to calculate the fee.

Last reviewed: 3 November 2026

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- Medical Records Regulation for Clinics
- How to Correct an Error in Medical Records