Adviceline: record-keeping guidance

Contemporaneous record-keeping is a fundamental requirement of practising as a physiotherapist. All practising members will be aware of the requirements by the HCPC to maintain adequate records. However, we may not always consider the impact of poor record keeping, particularly where records are evidence in clinical negligence cases. 

 

Appropriate record-keeping provides an accurate and complete account of the patient assessment, findings, diagnosis, care planning, treatment and the delivery and evaluation of care. In litigation cases remember: if it is not recorded it did not happen! Your records are critical if an allegation of negligence is made against you. They will be assessed by independent experts and the courts to determine the standard of care you provided and the rationale for your diagnosis and management plan. Claims of mis-diagnosis have increased over the past 15 years. Are you recording sufficient detail for others to understand what happened during a treatment or course of treatment? The CSP’s professional liability insurance lawyers report that the factual accuracy of events as recalled by the practitioner and the patient can be contentious unless supported by the physiotherapist’s records. Written records and other evidence are vital in the outcome of a claim.

 

Notes must be legible, accurate, clear, and precise, with sufficient detail for an independent expert to make a clear opinion about what happened.

 

Records must be kept for as long as they may be needed to support any legal claim. This time period can vary according to the type of claim. In line with NHS practice, we advise members to keep all adult records for eight years from the date of the last treatment. Other types of record may need to be kept for longer and some organisations also requires records are kept for longer.

 

Comprehensive, contemporaneous and adequate record keeping can have a vital role in determining the outcome of a litigation case, and can support any regulatory proceeding against a practitioner.