It’s really important for a therapist to keep good client consultation records. Full and clear records are essential for your therapist insurance policy to defend any allegations of negligence made against you.
How records can help with therapist insurance claims
Keeping comprehensive records is simply good professional practice. However, another good reason is that well maintained records will help your therapist insurance to give you the best possible defence. They can confirm your account of the facts. Furthermore, they can also help to discredit false allegations against you. We list below information which we would recommend that you include in the client records you keep.
- Full name of client
- Date of consultation
- Details of lifestyle and medical history where these are relevant to the therapy you give
- Brief description of the therapy or treatment given
- Unusual reactions to the therapy or treatment given
- Details of patch tests carried out, if any
- Any contraindications you identify
- Advice or recommendations you give
- Relevant comments made by the client about the therapy you provide
- Details of aftercare advice
- Any consent forms should be kept with the record
General points about record keeping
Keep your client records to the point, accurate and factual. Try not to use information in your notes which would be hard to substantiate. It will then be simple to identify information that would be valuable with regard to any therapist insurance claims that may arise.
Carry out a full consultation before each therapy or treatment. You should update client information every time they visit you. If you keep paper records, ask your client to put their signature against any changes that you note.
Ensure that you continue to give your client advice and information about their ongoing therapy and care. Where appropriate, be sure to offer them any choices that are available to them.
If you are a therapist renting a room within another business, you need to be certain who owns the client records. It would make good sense to have a legally binding document drawn up which sets out clearly who has access to the records and who owns them if you stop working there. If you have a Salon Gold therapist insurance policy, you can add legal expenses cover. This will give you a valuable 24 hour Legal Helpline which will give you all the advice you need.
Storage & confidentiality of client records
You should keep your client records confidential, secure, and protect your clients’ information from unauthorised disclosure. If you keep paper records, you should lock them away safely. If you keep computer records, be sure to password protect them. Also, you will need to comply with the Data Protection Act. The aim of this legislation is to control the way the data is handled and prevent it from being used unethically. It also gives legal rights to people who have their information stored on their records. You will need to register with the Information Commissioner in connection with this. Your clients have the right to request a copy of their records. Follow the procedure recommended in the Data Protection Act and keep a record of it in their notes.
We would recommend that you keep your client records for at least 7 years from the date of the last treatment. If you have concerns about any clients, or in the case of a minor, it’s best to keep them indefinitely. If you dispose of any records, you should shred them or burn them safely.
Client records that are concise but contain all the relevant information are essential to your therapy business. If the unexpected should happen and a client decides to sue you for damages, your therapist insurance will step in. However, it will be able to secure the best outcome for you if you can evidence the facts of what happened (and what did not happen) through good record keeping.