If a patient slipped or fell while meeting with you, would you know what to do?
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?
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.
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.
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Article written by: Scott Shelly and Ashlee Sherman of Barry.Nilsson. Lawyers
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