Good Records

Your greatest ally

As healthcare professionals, physiotherapists can be the subject of complaints by patients. The chances of successfully defending such complaints, and refuting allegations that could damage your reputation, are significantly higher if accurate and thorough clinical records have been kept.

The importance of comprehensive clinical records in the defence of a complaint or a claim for compensation therefore cannot be overstated. Patient records can be admitted into evidence in legal proceedings, so good records will be very persuasive in the mind of a peer, or a judge when determining, even many years after the event, whether the practitioner or the patient’s version of the events is correct. Put simply, in an adversarial context, if it’s not recorded it didn’t happen, and poor records tend to imply poor care. 

As a guide, you should keep the following records in legible form in relation to every patient treated:

• The patient’s name and address.
• If the patient is under 16, the name and address of a parent or guardian.
• The patient’s date of birth.
• The date of each treatment.
• A description of the treatment administered.
• The history provided by the patient and their presenting complaint.
• A description of the findings on assessment after the treatment.
• The treatment plan and the estimated cost if this is significant.
• The information and advice given, particularly if it contains warnings against certain activities or requests to return or see a general practitioner if a certain conditions or symptoms develop.
• Written consent (if any).
• Personal or actionable comments are excluded from all records

You can use abbreviations but it is important to use these consistently. Remember to always date the notes on the date you are writing the notes. If you do not have an opportunity to write the notes until after the day of the treatment, enter the date of when you are writing the notes and also clearly state the date the treatment was provided.

It is extremely important to record all tests that are performed and the outcome of your testing, including both positive and negative results. If a patient’s perception is that they’ve had a poor or less than expected outcome, you will need to be able to establish that you properly assessed the patient in the first instance and determined there were no contraindications to the care path you followed. If for example, part of your assessment involves asking questions of a patient, ensure that you record their replies, even if it’s in an abbreviated form in your notes.

It is good practice to make a reference to having seen any other diagnostic reports,  scans or radiological reports in your notes, and to document what reports have been read.

It is also good practice to make a record of how the patient felt or responded following your consultation / treatment, helping to refute allegations of patient dissatisfaction with you care.    

Test yourself by taking a random selection of your records, looking at them objectively  and testing how well they reflect all that has occurred. Even though it is sometime after the consultation, is the information leading to your diagnosis / prognosis and the care path you recommended, easy to follow? Consider it in an adversarial context where it is alleged that your care was substandard and where your records would be scrutinised by others.   

The reality of your profession is that you may face complaints from patients but by maintaining legible, consistent and thorough records you give yourself the best chance of defending any claims that might arise. Good records are the key to a good defence in the event of a complaint or a claim for negligence against you. In the event that such a challenge to your professional reputation arises, records form a strong base in protecting your hard-earned reputation.