The Importance of Effective Note Taking

If a claim was held against you about treatment you gave last week, would your notes help or hinder your recollection of what happened? What if the claim was from treatment you gave two years ago?

This blog explains why effective note taking is essential in the field of complementary therapy and how you can maintain adequate clinical notes.

This blog is part of the Don’t risk it series facilitated by IICT’s trusted insurance partner BMS and written by Scott Shelly and Ashlee Sherman of Barry.Nilsson. Lawyers.

What is effective note taking?

Practising effective note taking is an important part of client care for complementary therapists. Complementary therapists should ensure that their notes contain sufficient detail including an outline of a client’s history, diagnosis, assessment, treatment options, treatment plan, consent obtained, and any treatment provided. Further, clinical notes should also include a record of all communication with clients. Maintaining accurate and detailed clinical notes will assist a complementary therapist if a client’s care is being transferred or to prepare any referrals to other treating practitioners. Finally, in the unfortunate event that a client makes a complaint against a complementary therapist, having complete and accurate notes on hand is often the best defence.

What could happen if notes are poor?

Failing to maintain adequate clinical notes may amount to a breach of professional standards. A complementary therapist should keep in mind the general code of conduct in respect of general health services which is enforced by the various health complaints entities across Australia. Complementary therapists also have obligations as set out in the International Institute for Complementary Therapists' Code of Ethics. A complementary therapist has an obligation under this code to conduct themselves professionally so as to comply with the generally accepted standards of moral behaviour and decency. This extends to maintaining clear and accurate records to effectively treat clients and monitor their health and wellbeing.

How to take effective notes

There’s a few things complementary therapists can implement to help ensure they are practising effective note taking, such as:

• ensuring that notes contain all information which would be needed for a practitioner taking over the client’s care;
• always assuming someone else (including the client) will see the notes;
• obtaining and documenting clear, complete and accurate client information;
• writing notes contemporaneously;
• if any information is retrospectively added to notes, ensuring this is clearly recorded as an amendment by noting the name of the person making the amendment and the date; and
• always detailing consent obtained from the client.

Additional safeguards for clinics to help ensure that all complementary therapists are practising effective note taking may include training for all new staff on note taking and professional obligations relating to effective note taking. Clinics may also consider developing and implementing note taking policies and procedures.

Please be advised

Barry.Nilsson. Lawyers communications are intended to provide commentary and general information. They should not be relied upon as legal advice. Formal legal advice should be sought in particular transactions or on matters of interest arising from this communication. 

BMS Risk Solutions Pty Ltd AFSL 461594 ABN 45 161 187 980 / BMS Risk Solutions (NZ) Limited FSP 696531, NZBN 9429047279339 (BMS) is the official and exclusive insurance broker for the Australian and New Zealand IICT Member insurance program.

Learn more about IICT’s trusted insurance partner BMS or IICT’s insurance program.

Article written by: Scott Shelly and Ashlee Sherman of Barry.Nilsson. Lawyers

About the Authors:

	Barry.Nilsson. is a national firm specialising in Insurance & Health Law, Family Law and Wills & Estates.
	The BMS group provides cover to more than 700,000 healthcare and regulated professionals through 100+ associations across Australia, Canada, Europe and New Zealand. This experience gives BMS the ability to create and deliver significantly continuously evolving member centric insurance programs. This includes ensuring broad, market-leading coverage, evidence-based risk management and exceptional member service.