WHAT PATIENT RECORDS SHOULD I KEEP AS A THERAPIST?

July 24th, 2019 Posted by Acupuncture, Alternative Medicine, Consent forms, Consultation Forms, GDPR, Holistic Health, Hypnotherapy, Insurance, Medical History Form, Paperless, Uncategorized No Comment yet

As a Therapist. you need to keep a lot of information about your clients and their treatment.

In fact, your insurance against malpractice or negligence claims policy demands it and Insurers can be quite specific. 

I checked the small print from Professional Indemnity Insurance policies for Alternative practitioners. Here are some things I discovered, I hope they help.

YOUR INSURANCE DEPENDS ON YOUR RECORDS

Insurers require you to take consultation records and then retain those records. One policy I checked asked for five years, but most require seven years, after the last treatment given. 

Insurers advise that you keep the records of minors for at least 7 years after the minor reaches 18.

You should record the client’s full name, date of consultation and notes on their lifestyle/medical history. Also, you should record the treatment you gave the client.

Notes should at least include a brief description of the therapy or treatment. 

The therapist must adequately record each and every treatment given to each and every client. 

The record is to include full details of the consultation process, the treatment, the result of the treatment and any aftercare instructions given where appropriate.

Any adverse reaction to the therapy or treatment must be recorded either separately or as part of the notes already used.

RECORDS MUST BE ACCESSIBLE

You will be need to produce your records of the client/event In the event of a claim. This is to protect you in the event of a claim against you.

Where therapists work in a gym, sports or leisure centre, or a shared practice often the Centre keeps these records.  

You must advise the Centre of any unusual events or of any injuries sustained during your class. 

You must ensure that the Centre will give you access to your records. To protect yourself in case a claim is made against you in the future.

You should record the name and brief details of the person. The date of the session and the therapy given, at demonstration sessions or public events.

If you give Yoga, Pilates, Fitness, Exercise, Meditation therapy, record the name and brief details of the person, date of the session and any other relevant facts.

When new clients attend your class, you should talk to them and ensure that there is no reason why they should not attend your class. If in doubt you should ask for their GP’s confirmation that they can safely participate in your class. 

At the start of each class please ask all participants is there any change in their circumstances that might affect their ability to participate in and complete the class safely.

You must produce your records of the client/event. You must adequately record each and every treatment given to each and every client. This protects you in the event of a claim being made against you.

WE CAN HELP

Using iPEGS forms is economical, quick, tidy, neat and professional. No papers to find, no filing to do.

By using the iPEGS Paperless System for your Consultation Forms, Consent Forms, Medical Histories and Treatment Plans, you can be sure that your data is safe. Saved to the cloud there is no risk of a computer breakdown losing all your data. As the data processor we store and encrypt your data in a secure, state of the art, UK data centre.

We are Cyber Essentials Certified giving you peace of mind that our defences will protect against the most common cyber-attacks.

We have achieved the IASME governance standard in relation to GDPR where we have demonstrated wider governance for management of the controls protecting personal data.

If you would like to know more simply email me: steve @ipegs.co.uk or call me directly on: 01244 955350 and we can discuss how iPEGS can help improve your client’s experience.

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