PHYSIOTHERAPIST
The video found within the following link gives a brief overview of record keeping in relation to Physiotherapists. This is delivered by Priya Dasoju, a professional advisor from the Professional Advice Service: https://www.csp.org.uk/publications/record-keeping-guidance
Record-keeping: Key Considerations
A good record will enable an independent reader to understand what conversations took place with a patient, what information was exchanged, the extent of any examination performed, what treatment was provided and what clinical reasoning decisions were made. The following points should be kept in mind when generating both paper and electronic records:
The information must be clear to another health professional/the patient (including the use of short forms)
Written records should be:
- Legible and written in permanent ink
- Signed at the end of the record
- Paginated, including date of consultation and time when appropriate
- Amendments should be dated, timed and signed and the original entry still clearly visible
- Electronic recording systems should be able to:
- Show who has made the record
- Show revisions or amendments
- Lock the notes