“Records help protect your and your clients”

Why do my records matter?

Because they help protect you and your clients. If there’s ever a complaint or claim, your treatment notes can form an important part of the evidence. They show that the treatment took place, how you assessed suitability, your clinical reasoning, what was discussed, and why you made each decision. Good record keeping also supports continuity of care, backs up the pre treatment information you gave, and reinforces any post treatment advice you provided. 

What to record

The information you record will depend on the activity you practice. You should follow your training and best practice guidelines. Your Balens policy includes a record keeping condition that sets out the minimum information required in the event of a claim. As a practical guide you should look to record the following information:

Details of any pre-treatment/session consultation including the presenting issue, relevant medical conditions, medications, allergies and contraindications. Suitability assessment and whether informed consent has been taken (and how).
Treatment plan and adjustments planned activity and techniques and whether any modifications or adjustments are being made to ensure suitability. You should look to include the rationale for any decisions made. This should include a record of any pre or post session information provided.
Session details, include date/appointment times, client responses, outcomes or details of any adverse events.
Testing and safeguarding evidence of patch testing where appropriate.
The full record keeping condition can be found in your Balens policy wording.
Your records should be kept in a durable medium, and you need to ensure access in the event of a claim.

How long to keep records

Your Balens policy includes a condition that specifies you must keep your records as follows in order to comply with the policy:

• For treatment with adults a minimum of 7 years
• For treatment with minors, for 7 years after they turn 18.
• Vulnerable adults: consider retaining records beyond 7 years, as limitation periods may be extended by the courts.

Data protection law generally requires that records are kept for ‘no longer than necessary’, although the exact time is not specified and depends on your circumstances. Records may be kept where this is necessary for the establishment, exercise or defence of legal claims. If you are unsure, seek appropriate legal or professional advice.

 

Who owns the notes? Who can see them?

• Ownership: in many settings, patient records are the practitioner’s property-even if you move practice, refer the client on, or supervise a student under your insurance (in which case, the records are yours).
• Where you are working in a clinic or as part of a multi-disciplinary team, it is important you keep individual client records or can ensure access in the event of a claim.
• Clients may also have rights to access their personal data under data protection law.

If you move, sell, or stop practising

You must ensure you have ongoing access to your treatment records for insurance and professional purposes. This may also be important in the event of illness/incapacity (e.g., via a Will or Power of Attorney).

Record keeping in action – claim experience

Example one:

A client attends a session with their therapist. As part of the consultation, the therapist asks about allergies and record the answers in their treat records; the client does not disclose any. The therapist later recommends a product that happens to contain an ingredient the client is allergic to, and the client suffers an adverse reaction.

In this scenario, the consultation information is important evidence. It shows:

• The allergy question was asked clearly as part of standard practice.
• The client did not disclose the allergy at the time.
• The recommendation was made based on the information provided.
• These records help demonstrate that the therapist exercised reasonable care and was not negligent. 

Example two: 

During a group fitness class, a participant alleges the instructor pressured them to continue despite reporting discomfort, leading to a strained muscle. They later claim the instructor ignored their concern.
In this scenario, the records form an important part of the evidence. They show:

• Pre session screening recorded; no contraindications disclosed.
• Risk assessment and a brief class plan documented.
• Attendee list with date/time and instructor details.
• Notes of the modifications recommended and when they were given.
• Aftercare recorded, including advice provided and any signposting to medical review.

Clear, timely notes, kept in a durable format and retained in line with your Balens policy, support good care and help protect your cover if issues arise.