It is becoming more common for a group of different professionals involved in the delivery of patient care to input into one shared or unified record (in either paper or electronic format). This is perfectly acceptable practice.
The professional and statutory requirement to keep in mind is that the physiotherapist must keep a record of their intervention.
Physiotherapists are autonomous practitioners and thus provide appropriate intervention according to the assessed needs of their patients.
The physiotherapist should record the information they obtain into whatever repository their employer requires (for example, this could be within the medical ward notes if it gives the capacity to document physiotherapy treatment and decision making appropriately).
In circumstances where physiotherapy staff are asked to contribute to the main medical record (for example around the basic details of care) but there is no facility to capture decision making and intervention details, then a separate record should be maintained. However, duplication of effort around record keeping should be minimised.
The CSP contributed to a research project, conducted by the Royal College of GPs, looking at issues relating to the shared record in primary and community care.
This sets out 16 principles and guidance as a means of increasing public and professional confidence in shared record keeping. This is a key document for physiotherapy staff working in these sectors.
The Welsh Government has also published guidance on the sharing and exchange of personal information between different partners in the health and social care environment.
The current direction of travel in UK health policy is to give patients better access to their health records, in order to empower them to make informed decisions about their care.
Further work on making records understandable and accessible will be required to fully deliver on this in a meaningful way for patients.