Physiotherapy staff have a professional and legal obligation to keep an accurate record of their interactions with patients. These records are legal documents, which can be called upon in a variety of situations. Comprehensive patient records also help to drive high standards of patient care.
Since physiotherapy records are legal documents, physiotherapists are expected to follow legal frameworks alongside professional body guidance and any local policies that are in place.
This page contains FAQs around record keeping and the guidance paper provides an overview of a physiotherapist’s obligations for maintaining accurate records. It will also signpost you to key documents that provide further information related to specific aspects of record keeping, for example the Data Protection Act 2018 and the Information Commissioner’s Office (ICO).
Did you know...
- Physiotherapy staff have a professional and legal obligation to keep an accurate record of their interaction with patients.
If you use a smartphone to text or call patients, it stores their name and contact details – this counts as ‘keeping records’.
- You must be registered with the Information Commissioner’s Office if you or your organisation keep patient records, unless a legal exemption applies.
- Your duty to share information is as important as your duty to maintain patient confidentiality (Caldicott Review in England 2013).
- The use of SNOMED CT is now being driven by health policy and within NHS England its use is mandated.
- All record keeping is governed by the Data Protection Act 2018. The Data Protection Act 2018 is the UK’s implementation of the General Data Protection Regulation (GDPR).
Being able to make and maintain records is a requirement of your HCPC registration.
Keeping detailed records is a requirement of your CSP membership.