Due for review: 2015 Health Records Background

Record keeping is an important component of professional physiotherapy practice. Over the last two decades the need for high standards of documentation for physiotherapy records has increased due to a combination of professional, ethical and legal requirements. Failure to maintain appropriate clinical record would cause considerable difficulties in respect to any legal proceedings, e.g. allegations of negligence. It would also in all probability be a breach of government legislation covering clinical records. The purpose of clinical record keeping is 1 • To provide an accurate and comprehensive account of patient care with clear treatment plans and the relevant interventions by health professionals • To record the chronology of events, any problems that arise, and the action taken in response to them. • To assist the continuity of care amongst professionals and provide written evidence that the service has been delivered. • To meet legal, professional and statutory requirements