Alberta doctor sanctioned for patient charts described as ‘chaotic,’ illegible, incomplete

An Alberta family physician is facing sanctions for failing to create adequate records for a vulnerable young patient and repeatedly ignoring the college’s attempt to contact him.In a decision reached on Feb. 23, 2026 and released on May 11, 2026, the Hearing Tribunal of the College of Physicians and Surgeons of Alberta concluded that Dr. Johannes Botha should have his licence suspended for 60 days and a “modest” fine of $500 as well as $6,500 to cover the college’s costs.The complaints against Dr. Botha centred around the adequacy of the records he created for a patient he treated between 2007 and 2022. Dr. Botha had been the family physician for the patient, who was a minor during that period and had multiple mental health diagnoses, including intermittent explosive disorder, oppositional defiant disorder, ADHD, depression and Tourette syndrome. The patient estimates that she visited Dr. Botha an average of four-to-five times a year.After experiencing issues with Dr. Botha’s secretary, the patient had to switch to a different family doctor. The patient requested her medical records from Dr. Botha’s office to bring them to the new family doctor, but upon review of the records, she found they only consisted of test results, x-rays and referrals and were missing the doctor’s notes from the patient visits. The patient subsequently filed a complaint to the college, and following the complaint, she received an envelope with more documentation.During the hearing to determine the merits of the case, which was held last year, the tribunal called up an expert witness to weigh in on the quality of Dr. Botha’s notes. The witness testified that he found Dr. Botha’s notes to be “fairly chaotic with regards to presentation. He also noted that most of the records were handwritten and some were “not very legible.”“There was no sign of a cumulative patient profile recording the patient's medical history, social history, allergies, or treatments. There was no record of who was present with the patient at appointments and weights. There were very few entries regarding presenting symptoms, history, vital signs, physical examinations or percentiles,” the hearing tribunal wrote, summarizing the witness’ remarks.In addition, the expert witness also pointed out the lack of records relating to virtual visits, symptoms of mental health, the severity of the patient’s depression, or developmental milestones. “The failure of Dr. Botha to maintain a n accurate patient record for the Patient is a breach of the Standard of Practice,” the tribunal wrote. “This failure was longstanding and does not reflect intermittent errors or omissions. They reflect a systemic failure by Dr. Botha to comply with the minimum requirements relating to recordkeeping for a patient with significant and complicated health conditions.”The other issue at the centre of this case was Dr. Botha’s failure to respond to the college and cooperate with the investigation. Between May and December 2024, the college reached out to Dr. Botha on 10 occasions though registered mail, phone and email. The college had records of delivery for the registered mail and the voicemail, confirming the Dr. Botha did receive the messages. In addition, Dr. Botha did not participate in any of the tribunal hearings. “Dr. Botha was provided every reasonable opportunity to participate in the investigation and that Dr. Botha refused to avail himself of these opportunities. This represents a failure of refusal to cooperate with an investigator and meets the definition of unprofessional conduct,” the tribunal wrote.In addition to the suspension and the monetary penalty, Dr. Botha will also be required to enroll and complete a record-keeping course and participate in the college’s Individual Practice Review program.

Alberta doctor sanctioned for patient charts described as ‘chaotic,’ illegible, incomplete

Register for free access or login.

Related Topics