How to correctly keep a patient record in physiotherapy?

1 April 2026Anna Górska

A patient record isn't just paper to fill in -- it's medical documentation that protects both you and the patient.

A patient record isn't just paper to fill in -- it's medical documentation that protects both you and the patient. In a dispute, a complaint, or a KIF (Chamber of Physiotherapists) inspection, the record is evidence of your work and your professionalism.

In this article you'll learn exactly what should go into a patient record, what the legal requirements are, and how to avoid the most common mistakes that cost physiotherapists a great deal of trouble.

Legal basis -- what does the law say?

Documenting a patient's physiotherapy care is governed by:

Regulation of the Minister of Health of 6 April 2020 -- "on the scope, form and manner of keeping medical records by healthcare providers"

The Act on Patients' Rights and the Patient Ombudsman -- an obligation to keep patients' medical records

The Labour Code -- requirements regarding professional confidentiality

The GDPR -- protection of personal data

There's no ambiguity here: every physiotherapist registered in RPWDL (Register of Entities Performing Medical Activity) must keep a patient record. It isn't optional.

Mandatory elements of a patient record

Every record must contain the following sections:

1. Patient identification data

Information that lets you unambiguously identify the patient:

Full name (as it appears on their ID document)
PESEL (Poland's national identification number; or another ID number if the patient has no PESEL -- e.g. an EU citizen without a Polish PESEL)
Date of birth (redundant with PESEL, but always record it)
Home address (street, house number, city, postcode)
Phone number (for contact)
Email address (if the patient consents)

2. Health history (medical interview)

Questions you should ask the patient at the first visit:

Primary diagnosis -- what's bothering the patient or what brought them to you (e.g. "back pain", "knee injury", "post-stroke condition")
History of related complaints -- have they had similar problems before? When? How long did they last?
Past illnesses -- surgeries, fractures, infections, serious illnesses
Coexisting conditions -- do they have diabetes, hypertension, epilepsy, other chronic conditions?
Allergies (to medication, materials, thermal packs, etc.)
Current medication -- what medication are they taking (particularly important: anticoagulants, corticosteroids, muscle relaxants)
Previous physiotherapy -- have they had physiotherapy before? Where? Did it help?
Contraindications -- what could harm them (e.g. a patient with metal implants can't undergo electrotherapy)

All of this should be recorded at the first visit and never changes (unless the patient reports that something has changed).

3. Initial functional assessment

This is mandatory and should be the first thing you do. The assessment must include:

Range of motion (ROM) assessment:

Degrees of flexion/extension in each joint
Recorded in a standard format: e.g. "Knee: flexion 0-130°, extension 0°"

Muscle strength (on a 0-5 or 0-100% scale):

0-5 scale: 0 = no movement, 5 = full muscle strength
E.g. "Knee extensor muscles: 4/5"

Pain (on a 0-10 or VAS scale):

VAS = Visual Analogue Scale (a 10 cm line, the patient marks a point)
E.g. "Pain: 7/10 on flexion"

Swelling (if present):

Circumference in cm (e.g. "Knee circumference: 42 cm")
Location: "Around the knee"

Basic functional activities:

Can they get up from a chair? Can they climb stairs? Can they lie down without pain?

Palpation findings (what you feel on palpation):

Muscle tension, tenderness, scars, skin temperature
E.g. "Bilateral tension in the thigh extensor muscle"

4. Therapy plan

This is the second mandatory element. The plan must include:

Physiotherapy diagnosis -- how you diagnose the patient's problem (e.g. "restricted knee flexion, post-surgical, with tenderness")
Therapy goals (minimum 3):
Main goal: what you want to achieve (e.g. "restore knee range of motion to 120°")
Intermediate goals: how you'll achieve it (e.g. "strengthen quadriceps", "reduce pain to 2/10")
Methods and techniques (what you'll do):
Physiotherapy treatments (electrotherapy, massage, kinesiotherapy)
Exercises (which ones? how many sets?)
Patient education (what does the patient need to know?)
Frequency and duration:
E.g. "2 visits/week, 4 weeks, 8 visits total"
Session length: "45 minutes"
Prognosis (what you expect to achieve):
"After 8 visits we expect a 20-30° improvement in range of motion"

5. Progress notes -- what you write at every visit

Notes you make at every patient visit:

Date and time -- always at the start of every note

Subjective patient status (what the patient says):

"Patient reports a 2-point reduction in pain since the last visit"
"Pain occurs mainly in the morning, after getting out of bed"
"Can now climb stairs holding the handrail without swelling"

Objective examination (what YOU observe):

ROM (range of motion): "Knee flexion: 120°"
Strength: "Quadriceps: 4/5"
Swelling: "Reduced by 2 cm in circumference"
Palpation: "Reduced tension in the extensor muscle"

Treatments performed (what you did):

"Relaxing massage of the quadriceps (10 minutes)"
"Electrotherapy: TENS (20 minutes), parameters: 50 Hz"
"Kinesiotherapy exercises: knee flexion and extension (3 sets of 10 reps)"

Treatment parameters (be precise!):

TENS: 50 Hz, pulse width 200 µs, duration 20 minutes
Ultrasound: 1 MHz, intensity 1.5 W/cm²
Laser: wavelength 808 nm, power 500 mW
Massage: technique, duration, pressure

Patient tolerance (how did they feel?):

"Patient tolerates treatment well, no adverse reactions"
"Skin redness after treatment (normal)"
"Patient reported mild tingling (expected)"

Adverse reactions (if any):

"Transient pain for the first 2 hours after treatment"
"Swelling reduced after treatment"
(Write nothing if nothing happened)

Notes (additional remarks):

"Patient is compliant: does home exercises regularly"
"Patient shouldn't do physical work until the next visit"
"Purchased an orthopaedic support, as I recommended"

Signature and date -- always initial each note

6. Plan for the next visit

What will you do next?
Are you modifying the plan?
Does the patient have home exercises to do?

7. End of therapy -- summary

When the patient finishes therapy (or discontinues it):

End date
Final assessment (ROM, strength, pain, function) -- compare with the initial one
Therapy outcomes: "Pain reduced from 7/10 to 2/10", "Knee flexion increased from 90° to 130°"
Recommendations going forward: home exercises, prevention, who to contact if things worsen
Prognosis: "We expect the improvement to hold with regular home exercises"
Physiotherapist's signature

Common mistakes (and how to avoid them)

Mistake 1: Missing PESEL

Problem: The record doesn't contain the patient's PESEL, or only initials.

Why it's a problem: KIF considers this incomplete documentation. PESEL is required to identify the patient.

Solution: Always ask the patient for ID at the first visit. Record the PESEL on the file.

Mistake 2: Incomplete initial assessment

Problem: The record contains no ROM, strength or pain data -- just "back hurts".

Why it's a problem: How will KIF verify that the therapy was effective? Without measurements (ROM, strength), you can't prove anything changed.

Solution: Always perform a full assessment (ROM, strength, pain, function) at the first visit. Record specific numbers.

Mistake 3: No updates to the therapy plan

Problem: The plan from the first visit never changes, even though the patient has been coming for 10 weeks.

Why it's a problem: The plan should be dynamic. If the patient is improving, the goals change. If they aren't improving, the plan needs modifying.

Solution: Reassess the patient (ROM, strength, pain) every 3-4 weeks and update the plan -- new goals, new methods.

Mistake 4: Weak treatment descriptions

Problem: "Massage, 20 minutes" -- nothing more.

Why it's a problem: Where? What technique? What pressure? Without detail, anyone could claim they did whatever they say they did.

Solution: Always describe precisely: "Relaxing massage of the quadriceps, using reflex technique, medium pressure, 15 minutes, patient tolerates well."

Mistake 5: Missing signature

Problem: Records written in the waiting room, without the physiotherapist's signature.

Why it's a problem: Without a signature, a record has no legal value. Who wrote it? When? Was it the physiotherapist or the receptionist?

Solution: Always initial every note (date + your signature or stamp).

Mistake 6: Storing records in the open

Problem: Patient records left in the waiting room or on a desk where anyone can see them.

Why it's a problem: This is a breach of GDPR and professional confidentiality. The patient has a right to privacy.

Solution: Keep records in a locked cabinet. Access only for you and the doctor (if a doctor works with you).

How to correctly store patient records

Retention period

Mandatory period: 20 years from the end of the calendar year of the last entry.

Exceptions:

Death caused by bodily injury or poisoning: 30 years from the end of the year of death
Records of children up to the age of 2: 22 years

Storage location

Locked cabinet (with a key)
Inaccessible to patients and unauthorised people
Protected from damp and light (an archive, not a patient room)
If records are digital: an encrypted server, password-protected access

What to do after 20 years?

After the 20-year retention period, you have two options:

Destroy the records (by shredder or incineration -- never in ordinary rubbish)
Archive them (if the records have historical value)

You can't just throw records in the bin -- that's a GDPR breach.

Examples of correctly kept records

[Solo] Example -- solo practice:

```

PATIENT RECORD

Full name: Jan Kowalski

PESEL: 75081234567

Date of birth: 12.08.1975

Address: ul. Warszawska 45, 00-001 Warsaw

Phone: 555-123-456

MEDICAL HISTORY (15.03.2026):

Primary diagnosis: Lumbago (lower back pain)
Related history: First episode of pain 2 months ago after lifting a heavy load
Past illnesses: Appendix surgery 10 years ago
Coexisting conditions: Hypertension (treated, Enap 10 mg)
Allergies: Penicillin
Medication: Enap, Ibuprom (occasionally)
Previous physiotherapy: None

THERAPY PLAN (15.03.2026):

Diagnosis: Muscular lumbago with restricted forward flexion

Goals: 1) Reduce pain from 7/10 to 2/10, 2) Restore forward flexion (currently 30°, target 60°), 3) Strengthen abdominal muscles

Methods: Relaxing massage, electrotherapy (TENS), kinesiotherapy, ergonomics education

Frequency: 2x/week for 6 weeks (12 visits)

Prognosis: After 12 visits the patient should be able to work pain-free

NOTE FROM 15.03.2026 (FIRST VISIT):

Subjective:

Patient reports lower back pain, worse on forward flexion and physical work
Pain: 7/10 (VAS scale)

Objective:

Range of motion:
Forward flexion: 30° (limited by pain)
Extension: 15°
Right lateral flexion: 20°
Left lateral flexion: 25°
Abdominal muscle strength: 3/5
Palpation: Tension in the back extensor muscles (causing pain), no disc bulge (good)

Treatments:

Relaxing massage of the back extensors and trapezius (15 minutes)
Technique: reflex, medium pressure, patient tolerates well
Electrotherapy: TENS on the lower back
Parameters: 50 Hz, pulse width 200 µs, duration 20 minutes
Patient reports reduced tension after treatment
Kinesiotherapy exercises: spinal flexion and extension (3 sets of 10)
Patient performs without difficulty

Post-treatment status:

Pain reduced to 5/10
Patient feels better, more mobile

Home exercises:

Relaxation exercises: 3x daily
Education: "Don't lift heavy objects for 3 weeks"

Next visit: 18.03.2026, 14:00

Signature: [physiotherapist/stamp]

Date: 15.03.2026

```

[Group] Example -- group practice:

In a group practice, each physiotherapist keeps their own notes, but patient records can be shared (if the patient sees different physiotherapists).

```

PATIENT RECORD - "FIZJOZDROWIE" PRACTICE

Full name: Maria Nowak

PESEL: 80101234567

Phone: 555-987-654

MEDICAL HISTORY (01.03.2026 - physiotherapist Agata Lewandowska):

Diagnosis: Post-traumatic neck pain (cervicalgia)
History: Car accident 3 months ago, previous physiotherapy didn't help
Illnesses: None
Medication: Ibuprofen (occasionally)
Allergies: None
Contraindications: None

THERAPY PLAN:

Goal 1: Reduce pain from 6/10 to 1/10
Goal 2: Increase neck mobility
Methods: Mobilisation, massage, manual therapy, stabilisation exercises
Duration: 8 visits

VISIT 1 (01.03.2026 - physiotherapist Agata):

Neck ROM: flexion 30° (normal 50°), right rotation 20° (normal 45°)
Pain: 6/10 during rotation
Treatment: Neck mobilisation (grades 1-3), neck muscle massage
Outcome: Pain reduced to 4/10 after treatment
Signature: Agata Lewandowska

VISIT 2 (04.03.2026 - physiotherapist Agata):

ROM: Flexion 35°, rotation 25° (progress)
Pain: 4/10
Treatment: Manual therapy (mobilisation), isometric exercises (3 sets)
Home: Neck exercises 2x daily
Signature: Agata Lewandowska

[...]

VISIT 5 (18.03.2026 - physiotherapist Piotr Kowalski - covering):

ROM: Flexion 45°, rotation 40° (very good progress!)
Pain: 1/10
Treatment: Strengthening exercises (4 sets), office ergonomics education
Note: Patient clearly better, highly motivated
Signature: Piotr Kowalski

```

See the difference? In a group practice, records can be shared, but each physiotherapist signs their own notes.

CTA: Want a ready-made patient record template you can print or fill in digitally right away? The STANDARD package includes a patient record template (PDF + editable Word), compliant with KIF and Ministry of Health requirements. No need to start from scratch -- just print and fill in. See FizjoReady packages →

Frequently asked questions

Q: Do I have to keep the patient record on paper, or can it be digital?

A: It can be digital, but GDPR requirements must be met: encryption, secure storage, password-protected access. Paper is simpler but harder to access on the move (you need a cabinet). Digital is more convenient but requires investment (an IT system, security). Many practices use a hybrid approach: paper in the practice + encrypted cloud copies.

Q: What if a patient requests access to their record?

A: Patients have the right to access their own data (GDPR Article 15). You should give them a copy of the record (disclose its contents, they can request a printout). This isn't a problem -- records are for the patient, you're just the custodian.

Q: Can I throw away an old patient record after 20 years?

A: Yes, but you must be certain 20 years have passed since the patient's last visit. If a patient's last visit was in 2006, you can dispose of the record in 2026. Dispose of it via shredder or incineration, not ordinary rubbish.

Q: If a patient doesn't show up for an appointment, do I need to make a note?

A: Yes. Write "Patient did not attend" with the date and time. This matters for the medical history and for you (if the patient later claims they never came, you have proof).

Q: Can I take photos of a patient's wound or swelling for the record?

A: Yes, but ONLY with the patient's written consent. The consent should specify: what will be photographed, where it will be stored, who can view it. Photographing without consent is a breach of GDPR and the patient's dignity.

Related articles:
- KIF inspections at your practice -- what to expect
- Legal form for a physiotherapy practice
- How much does it cost to open a physiotherapy practice