The Chartered Society of Physiotherapy The Chartered Society of Physiotherapy

Basket

View your shopping cart.

Documenting a health record

Principles of good record-keeping, across electronic records, shared records and short forms.

Principles of good record keeping

Principles of good record keeping

Physiotherapy staff have a professional and legal obligation to keep an accurate record of their interaction with patients.

Use of short forms/abbreviations

Use of short forms/abbreviations

Short forms in clinical practice save time when making entries to patient records, to be developed and later written up in full.

Shared records

Shared records

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.

Electronic records

Electronic records

Across healthcare there is a need for a much more efficient and transparent means of recording, transmitting and accessing reliable clinical information.

Countersigning entries and delegation

Countersigning entries and delegation

Registered AHPs remain accountable for the record-keeping entries made by students and support workers.

Competence in record keeping

Competence in record keeping

It is your responsibility to develop and maintain competence in record keeping.

Back to top