Physio Patient Record: Template and Fields

A patient record is not paper to fill in "for the sake of form"; it is medical documentation. In a dispute, a complaint or a KIF inspection it is the record of what you did and why. In this article we break the record into fields, give the legal basis for each, and separate what the law requires from what is good practice.

In everyday language the "patient record" is, in the regulations, the individual physiotherapy care record (karta indywidualnej opieki fizjoterapeutycznej): internal individual documentation kept within a physiotherapist's professional practice. Do not confuse it with the "patient card" (karta pacjenta) in Article 30b of the Act on Patient Rights, added by the Act of 15 May 2026 (Journal of Laws 2026 item 791): that is a document generated by the Medical Information System at the request of an authorized medical worker (patient data and selected individual medical data such as allergies), not the documentation you keep at the practice.

Short answer

A physiotherapist providing services within a professional practice keeps internal individual documentation in the form of an individual physiotherapy care record, started when the first service is provided (§ 62(1) and (3) of the Minister of Health regulation on medical records). If you practise only inside a medical facility under a contract with the entity running it, you make entries in the records kept by that entity (§ 62(2)). The record contains, among other things, the patient's identification, the diagnosis and description of functioning, data on the physiotherapy management, a description of the services provided, recommendations, the date of the entry and the identification of the physiotherapist (§ 49(4)). Records are kept for 20 years from the end of the calendar year of the last entry (Article 29 of the Act on Patient Rights).

Legal basis

• Act on Patient Rights and the Patient Rights Ombudsman: Article 24 (who may process data in the records), Article 25 (minimum content), Articles 26-27 (disclosure), Article 29 (retention). Consolidated text: Journal of Laws 2024 item 581, as amended.
• Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text Journal of Laws 2026 item 1391): § 1 (form and security), §§ 4 and 6 (entries), § 7 (classifications), § 8 (patient statements), § 10 (elements of individual records), § 49(4) and § 62 (physiotherapist's record).
• Act on the Physiotherapist Profession: Article 9(4) obliges a physiotherapist to keep and disclose medical records under the Act on Patient Rights.
• GDPR: data protection at a physiotherapy practice.

The general picture of a practice's medical records is in our guide to medical records in physiotherapy, and the starter set in documents for a patient's first visit.

Record fields with their legal basis

The table below collects what follows from the regulations. The regulation lists the elements of the records but does not prescribe a layout, so you choose the layout and field names yourself.

Field	What to enter	Basis
Patient: surname and first name	Full details from the identity document	Art. 25(1)(1) of the Act; § 10(2)
Patient: PESEL	PESEL if assigned; otherwise the name, issuing country and number of an identity document	Art. 25(1)(1)(e); § 10(2)(a)
Patient: date of birth and sex	Only when no PESEL has been assigned	§ 10(2)(b)
Patient: home address	In the first internal documentation created for the patient	§ 10(2)(c)
Statutory representative	Details of the representative where the patient is a minor, incapacitated or unable to consent knowingly	Art. 25(1)(1)(f)
Practice	Name and address of the entity, phone or e-mail, departmental code if applicable	Art. 25(1)(2); § 10(1)
Physiotherapist	Name, professional title, right-to-practise number, signature	§ 10(3)
Diagnosis	Name and statistical number of the diagnosis under the International Classification of Diseases and Health Problems	§ 7(1); § 49(4)(1)(a)
Functioning	Description of functioning taking into account the International Classification of Functioning, Disability and Health (ICF); past and coexisting conditions	§ 7(2); § 49(4)(1)(a)
Physiotherapy management	Data on the physiotherapy management and how it was carried out	§ 49(4)(1)(b)
Services provided	Description of health services provided; date and type of treatment	Art. 25(1)(3); § 49(3)(3)-(4) and (4)(1)(c)
Recommendations	Recommendations for the patient	§ 49(4)(1)(d)
Rulings, opinions, certificates	Information on documents issued	Art. 25(2); § 49(4)(1)(e)
Medical devices	Information on devices ordered by the physiotherapist	§ 49(4)(1)(f)
Date of entry	Date of every entry	Art. 25(1)(4); § 49(4)(2)
Referral	Attach if applicable	§ 49(5)
Patient statements	Consent to share information, authorization for records, consent to services, if made outside the Internet Patient Account	§ 8(1); see authorization to access records
Patient's e-mail	Where records are to be sent electronically	§ 10 (patient's e-mail address)

External documentation, meant for the patient, consists of certificates, rulings or physiotherapy opinions and other documents prepared at the request of the patient or authorized bodies (§ 62(1)(2)). As to the register of services: § 49(3)(1), to which § 62(4) refers, also lists the patient's sequence number in the register. If the record is kept electronically, a separate register is not required (§ 49(2)).

What to add as good practice (not a legal requirement)

The regulations do not name specific scales or tests, so the elements below are suggestions that make it easier to describe functioning and progress. Choose them to match professional knowledge and the type of therapy.

• History: reason for the visit, earlier similar complaints, allergies, medications relevant to therapy, contraindications.
• Initial and final assessment: measurable parameters (for example range of motion, muscle strength on a chosen scale, pain on a VAS scale, circumference), recorded so they can be compared.
• Therapy plan: goals (short- and long-term), methods, expected frequency of visits, criteria for changing the plan.
• Visit entry: the patient's reported condition, examination findings, treatments given with parameters, tolerance and any adverse effects, recommendations for the next visit.
• End of therapy: final assessment, recommendations for the future.

Do not write promises of results in the record ("after 12 visits the patient will work without pain"). Records describe condition, actions and recommendations; they do not guarantee an outcome.

How to make entries

• Entries are made immediately after the service is provided, and in paper records legibly and in chronological order (§ 4(1)).
• Every entry and every change to an entry carries identification of the person who made it: name, professional title, right-to-practise number, signature (§ 4(2), § 10(3)). In a group practice this means each therapist signs their own entries.
• Paper records carry a handwritten signature (§ 4(5)).
• An entry in paper records is not removed. A wrong entry is crossed out and an annotation is added giving the reason for the error, with the date and the identification of the person making the annotation (§ 4(6)).
• Pages of paper records are numbered and form a chronologically ordered whole; the first page carries the patient's full identification, later pages at least the patient's name (§ 6(1)-(2)).
• Documentation supplied by the patient is added to the record, a digital copy is attached, or the relevant information is noted (§ 6(4)).

Paper or electronic

The rule is to keep records in electronic form. Paper is permitted if a provision of the regulation says so or if organizational and technical conditions make electronic records impossible (§ 1(1)-(2)). A document kept in one form may not be kept in the other at the same time (§ 1(3)), so "paper at the practice plus a copy in the cloud" for the same document is not a solution consistent with that provision. We do not decide whether the exception in § 1(2) applies at your practice; we leave that point for a lawyer to verify. More on EDM in EDM in physiotherapy.

Records are secured if, on a continuing basis, access is guaranteed only to authorized persons (Article 24(2) and Article 26 of the Act) and effective, generally recognized protection methods are used; this requires, among other things, risk assessment and documented procedures for access and storage (§ 1(4)-(5)). Records left in the waiting room or on a desk do not meet that condition.

How long to keep a record

Records are kept for 20 years counted from the end of the calendar year in which the last entry was made (Article 29(1)). Exceptions: 30 years from the end of the year of death where the patient died as a result of bodily injury or poisoning; 22 years for records of children up to the age of 2; shorter periods for X-ray images kept outside the records (10 years) and referrals (5 or 2 years). After the period, records are destroyed in a way that prevents identifying the patient; before destruction they may be handed to the patient, the statutory representative or an authorized person (Article 29(2)).

Example: the last entry in a record is from 12 March 2006. The 20 years run from the end of 2006, so they end on 31 December 2026. You do not destroy the record earlier.

Common mistakes

1. An entry without the identification of the person and a signature. Required by § 4(2) and (5). A record in which it is unclear who wrote what and when is hard to defend in a dispute.
2. Correcting by erasing or blotting out. A wrong entry is crossed out and annotated (§ 4(6)).
3. A description of the service that is too general ("massage 20 minutes"). The records must contain a description of services provided (Article 25(1)(3); § 49(4)(1)(c)). Record the area, technique, time, parameters and the patient's reaction.
4. No diagnosis or description of functioning using the ICD and ICF classifications (§ 7).
5. No date of entry, or entries out of chronological order.
6. No update of the plan. The regulations set no review frequency, but a plan that does not change as the patient's condition changes does not reflect the physiotherapy management you describe in the record.
7. Records accessible to unauthorized persons (§ 1(4)).

Sample visit entry (fictional data)

Sample entry (adapt it)
Date of entry: 15.03.2026. Patient: [name], PESEL [number]. Referral: [if applicable].
Diagnosis (name and number under ICD): [enter]. Functioning (taking ICF into account): [description, for example limited bending and lifting].
History and initial assessment: [condition reported by the patient; range of motion, strength, pain on the chosen scale].
Physiotherapy management: [goals and plan: methods, frequency].
Services provided: [massage: area, technique, time; physical therapy: type, parameters, time; kinesitherapy: exercises, sets]. Patient's reaction: [tolerance, adverse effects].
Recommendations: [home exercises, restrictions, date of next visit].
Physiotherapist: [name, professional title, right-to-practise number], signature.

Frequently asked questions

Must I keep the patient record on paper, or can I keep it electronically?

The rule is electronic form; paper is permitted where a provision of the regulation so states or where organizational and technical conditions make electronic records impossible (§ 1(1)-(2) of the regulation). The same document may not be kept in both forms at once (§ 1(3)). An electronic system must ensure, among other things, identification of the person making an entry and the time of the entry (§ 1(6)).

What should I do when a patient asks for access to their record?

Records are made available to the patient for inspection, by an extract, transcript, copy or printout, electronically, or on a data carrier (Article 26(1) and Article 27(1)). The practice may charge a fee for a transcript, copy or printout, a data carrier and a scan, but the first time the records are provided to the patient in the requested scope and in those ways, it is free (Article 28(1) and (2a)(1)). See a request for access to medical records.

Can I destroy an old patient record after 20 years?

Yes, but only after 20 years counted from the end of the calendar year of the last entry, and in a way that prevents identifying the patient (Article 29(1)-(2)). Longer periods apply for death resulting from bodily injury or poisoning and for children up to the age of 2. See archiving medical records.

Can I photograph a patient's wound or swelling for the record?

A photograph of a health condition is data concerning health, so before you start settle the basis and scope of processing and inform the patient (see patient consent to treatment). We did not check in the source the detailed requirements for the form of consent to photographs; we leave that point for a lawyer to verify.

Is the "patient card" under Article 30b of the Act on Patient Rights the same as my record?

No. Article 30b describes a document generated by the Medical Information System, covering the patient's data and selected individual medical data (among others allergies, vaccinations, significant health problems), made available to medical workers on request. The individual physiotherapy care record is your internal documentation under § 62 of the regulation.

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Legal status as of: 28 October 2026

Legal basis: Act of 6 November 2008 on Patient Rights and the Patient Rights Ombudsman (consolidated text Journal of Laws 2024 item 581, as amended by Journal of Laws 2026 items 26 and 791), Articles 24-29 and 30b; Minister of Health regulation of 6 April 2020 on the types, scope and templates of medical records and the manner of processing them (consolidated text Journal of Laws 2026 item 1391), §§ 1, 4, 6-8, 10, 49 and 62; Act on the Physiotherapist Profession (consolidated text Journal of Laws 2026 item 584), Article 9(4). We did not check: technical standards for EDM and exchange with the P1 platform, rules on consent to photographing patients, or whether the exception to electronic form in § 1(2) applies at your practice (for a lawyer to verify).

Last reviewed: 28 October 2026

The TARCZA package contains instructions and a template for the patient record, a therapy plan, a treatment log, a treatment consent and rules on storing records. See the TARCZA package or compare packages.

Related articles:
- Documents for a patient's first visit -- the full set
- Medical records in physiotherapy
- Authorization to access medical records
- KIF inspection at your practice -- what to expect
- How to Correct an Error in Medical Records
- Patient Record: Software or Word Template?