A ‘health record’ means any record which:
- Consists of information relating to the physical or mental health or condition of an individual
- Has been made by or on behalf of a health professional in connection with the care of that individual, in accordance with the Data Protection Act (Ch 29)
A record can be in paper or electronic format, or a mixture of both, and includes all the information relating to the health status and management of the individual patient.
There are various types of records in practice: summary or full records, shared records, uni-professional records and patient-held records.
Depending on the needs of the patient and the care setting involved, the record may be maintained by an individual healthcare professional or a group of different professionals across the care pathway.
The record may contain information about the current episode of care only, or may be a compilation of every episode of care for that individual in a given timeframe.
Record-keeping: content, layout and style
Whether using paper or electronic records, there are general principles that should be followed in relation to content, layout and style.
The standards for the clinical structure and content of patient records, compiled by the Health and Social Care Information Centre (HSCIC) in 2013, and supported by the CSP, outline generic clinical record headings and the information that should be recorded under each heading across the medical professions.
Physiotherapy staff work across a variety of settings and are required to maintain records in whatever system or format their employer specifies.
Staff should review the standards (above) to ensure that assessment, treatment, discharge and referral records include the information required to ensure consistent recording of patient data across all contexts.
See the webpage legal regulatory and employer responsibilities for profession-specific standards in record-keeping in the form of the HCPC standards, the CSP Code and the CSP Quality Assurance Standards.
While many physiotherapy staff use SOAP notes (Subjective/Objective/Assessment-Action/Plan) to document the patient record, other styles are in use.
Record-keeping: key considerations
It is important to understand that a court or disciplinary/investigatory panel will assume that ‘if it is not recorded, it has not been done’.
Therefore all action taken, decisions made or information provided should be recorded.
The following points should be kept in mind when generating both paper and electronic records:
- Pages of a written record should be numbered including date and time of consultation
- In paper format you must sign the records at the end of your notes
- Written notes should be legible and written in black ink
- In electronic format you need to be able to lock the notes and show revisions or amendments
- Amendments should be dated, timed and signed and the original entry still clearly visible
- Clarity of information to another health professional/the patient
- Use of short forms (see Use of short forms)
- Use of validated/recommended PROMS and PREMS
Section 6 of the CSP's Quality Assurance Standards highlights the specific standards expected of physiotherapists when keeping records.
Use of the CSP’s Record Keeping and Information Governance Audit Tool is helpful to ensure that records fulfil key requirements.
The NHS Professionals record-keeping guidelines is also a useful document.