No matter how good a physiotherapy practitioner you may be, things can go wrong. In the event that they do and you need to make a professional indemnity or medical malpractice claim, good patient records are crucial to the defence and timely resolution of the matter.
Ask yourself, how well would your records stand up if it came to a tribunal or court case? Here are some record keeping factors to consider:
Have you sufficiently captured the patient's history? Remember this may come out over a series of consultations, sometimes unexpectedly. It's important to add any new information on file when and as it's given - ideally including records of previous tests and treatments the patient has undergone
Are your records legible and easily understood by others? Sometimes it's a rush to make records during an appointment with a patient, but it's important that what you write (or type) is decipherable at a later time. Abbreviations used should be clearly understood and consistent across your practice in case a colleague treats your patient in your absence. Ensure your notes include relevant dates and signatures, as well as any documentation of findings such as x-rays and other tests.
Have you recorded any risks or warnings provided to the patient prior to tests or actions to demonstrate 'informed consent'? It is also critical to summarise patient feedback - both positive and negative - as treatments are undertaken and progress made. This includes recording any exercise programs that were demonstrated and undertaken with the patient - and ensuring they are fully aware of what is required before they leave the practice.
Why good records are critical
If you have to make a professional indemnity or medical malpractice claim, you will be asked to provide a copy of your patient's records.
Inadequate or incomplete records may limit your ability to demonstrate a defence against these claims or allegations made by others, including a tribunal or event court. This can cause intense personal or professional stress on physiotherapists. Poorly kept records may also lengthen the time it takes to build your defence by requiring additional research and information gathering to be undertaken to remedy the file. If the file is complete, the issues may otherwise be quickly and easily resolved.
So ask yourself, are your practice records complete, up to date and sufficient to protect you in the event that they need to be relied on at a later date? Ensure your records reflect your professionalism and high standard of patient care. Keeping detailed patient records takes time and attention but it's always better to be safe than sorry!
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Our advice is general in nature. To read the full General Advice Warning click here.