Guidance on record keeping

‘I provide physiotherapy led exercise classes for the general public. Do I need to keep records?'

Claire Fordham CSP professional adviser

Yes. If you are practising as a registered physiotherapist whatever the setting or context you must comply with the Health and Care Professions Council (HCPC) standards of conduct, performance and ethics.

Standard 10 outlines expectations of registrants’ record keeping practices. Managing these requirements needn’t be onerous though. What is required is a proportionate response in the context. 

Here are our top tips for physios to ensure you meet HCPC requirements for record keeping, to help demonstrate you have provided a reasonable standard of care when providing exercise classes. Start with risk assessments.

Consider the following:

  • your group population
  • what and how you plan to teach 
  • dealing with any identified health concerns of participants
  • size of classes 
  • the premises in which you will be teaching
  • how you might share information about participants if needed  
  • how you will store your records. They must be kept securely

Keep a record of your risk assessments and all the actions you take to manage risks. 

Here are some suggestions of how you might manage risk and keep appropriate records:

  • provide a class information leaflet to manage expectations of what will be provided and how this will be done
  • ask participants to complete a health screening form to enable you to check present and past medical history quickly
  • remember that professional disclaimers are never appropriate, do not add these to any documents
  • in any class information and on screening forms include a privacy notice outlining how you will gain consent to share information and
  • your duty to share information if required
  • begin each class by asking that anyone who has any new health concerns speaks with you individually 
  • keep a record of class attendance 
  • keep a record of what was taught during each class 
  • if you need to discuss a health concern with a participant you should document the conversation and any additional assessment, advice or
  • signposting given. 

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Author: Claire Fordham is a CSP professional adviser

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