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Legal aid - Setting the record straight

Joanna Howard, an employment lawyer with Thompsons Solicitors, examines the importance of good record keeping

Good record keeping is an integral part of the practice of physiotherapy and is essential for the provision of safe and effective care.

Maintaining full and accurate records can be time consuming but it is essential.

Whenever the Health Professions Council (HPC) receives a complaint about the standard of care provided by a physiotherapist the records relating to that service user will form part of the evidence to be considered by a regulatory panel.  

Records are the only contemporaneous note that a physio has of what was discussed, what assessments/reviews were undertaken and what treatment/advice was given to the patient.

Quite simply, if it’s not recorded in the notes, there’s no evidence that it happened.

Audits of patient records can assess the standard of record keeping within a practice and identify areas for improvement.

Many physiotherapists will have pro forma sheets to complete and store in the patient’s records.

These often provide a prompt for the information that should be recorded during the course of the treatment session.

Ultimately, the detail recorded in the patient’s records should make continuity of care easier.  

A record should be kept every time a patient is treated or professional advice or service is given and entries must be signed and dated.

This includes any communication that a physiotherapist has with another health professional about the service user.

If records are handwritten they must be legible.

And if they are updated, previous information must not be erased. Instead it should be made clear if the previous information has become obsolete.

If a physio is supervising a student then they should sign the patient’s record to confirm this.  

Service or patient user records should be used to record that the physio has fully explained the treatment and the risks and alternatives.

The fact that informed consent has been obtained from the patient must also be recorded.  

The HPC’s Standards of Conduct, Performance and Ethics does not provide further detail on what it expects to see in records but good practice dictates that matters such as previous medical history, the physio’s clinical reasoning, treatment plans and advice, including specific weights, repetitions, intensity and duration whenever applicable, clinical outcomes and records of referrals and discharge should be kept.

Never forget that patient records are confidential and subject to the Data Protection Act so care must be taken to ensure that they are protected against loss, damage or unauthorised use.  

The CSP has recently updated its guidance on record keeping.

For further information see: CSP Record Keeping Guidance: www.csp.org.uk/publications/record-keeping-guidance; the HPC Standards of Conduct, Performance and Ethics are at www.hpc-uk.org

  • Thompsons Solicitors advises the CSP on professional conduct cases
  • Sally Gosling is CSP’s assistant director for practice and development

 

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