Why Keep Records?Whatever therapy you practise, you will need to keep clear and accurate records of your activities for financial, professional and legal reasons.
What Records Do I Need To Keep?
- client records
- financial records
- training records and certificates
- insurance records and certificates
- professional membership records and certificates.
Client Records
Client Case History SheetsYou will need to devise your own best way of keeping your client records. Most therapists use some form of pre-printed client case history sheet or a computer-based equivalent. This document will act as a complete record of the client’s contact, personal and medical details, and will be used to detail the treatment that the client receives each time they attend for a session – see the example on page 103 (Figure 16).
You may need to include further details on your client case history sheet, but this will depend on the work you are engaged in and the need to comply with any legal, insurance or professional requirements related to your practice.
Figure 16.
case history sheet.
Keeping Client Contact Details
Whatever system you adopt for recording your client contact details, try to keep it as simple as possible. Aim to minimise the number of times you have to record the same details, for example by limiting the number of places in which you store your clients’ contact details to no more than two places – such as stored on your phone and on your client’s case history sheet. Keeping these details in a maximum of two places will cut down on any updating time and should mean that you will be less likely to forget to update
all the contact records.
Keeping Client Treatment Records
If you always work from home then you will be able to keep all your client records together either in your filing cabinet, if you keep paper copies, or on your computer. However, if you work from two or more locations, work from your clients’ homes or have a totally mobile practice, you will need to keep your client data in a way that you can easily carry it around with you. This could mean that you will find it more efficient to keep your client case history records on your laptop computer, and also store their contact details on your
mobile phone so that you can make any quick calls whilst travelling or when working from different locations.
What Should I Include In My Client Treatment Records?
When you record your client sessions you should include an overview of your client treatment plan, and any particular techniques that you used, or supplements or herbs you may have prescribed. You may also find it helpful to document your clients’ responses or outline their possible future needs or how their treatment could be developed. This will, of course, differ according to the therapy you are practising.
Client Records – The Golden Rules
The key points you should take note of are:
- All your records should be factual and accurately record your session with your client – including the details of any treatments and responses. You should also include the date (and if appropriate, the time) of the session.
- Your records should be easily legible, either typed or handwritten in ink and not pencil – this is so that none of your notes can be erased.
- You should include full details of your client’s treatment plan i.e. what issues did the client present with? What treatment did you give? What follow-up work do you intend? Document any decisions which were made and whether any information was shared with others.
- If you have had any contact with the client in between sessions, for example phone calls, emails or letters – make sure you write these up or include a copy of the correspondence and your response in the client’s file.
- If you use abbreviations, you should make sure that these are consistent – and if you have your own form of abbreviating certain words or statements make sure you include a breakdown of what these are describing.
- Don’t include any comments which are speculative rather than factual, or which could be taken to be offensive.
- Any mistakes in your handwritten notes should be crossed out – don’t use Tippex to mask the mistake.
- Try to get into the good habit of allowing time at the end of each session to write up your notes as soon as the client has left.
- You should also keep copies of your diaries or appointment records. Make a note beside each entry as to whether the appointment was kept. If the appointment was cancelled, make a note of the reason for the cancellation.
If you are still in any doubt as to the degree of detail you need to keep, you might like to raise this matter with your training school or tutor. I usually work to the worst case scenario – if I had to present in court the details of my contact with a client, how useful and efficient are the details I have recorded? I generally find that this helps to focus my mind appropriately – effectively preventing me from recording extraneous information, or recording anything that I wouldn’t want the client to read or become public knowledge.