Professional indemnity insurance and business insurance for Australian professional

Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for AEPs to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many AEPs would benefit from learning more about good record keeping.

Record keeping and insurance claims

Why is an insurer so concerned about record keeping? It’s because client records can greatly impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to poor or unexpected outcomes following sessions, such as an injury, leading to the client complaining and possibly seeking some form of compensation.

The wellbeing of clients is paramount, therefore reducing the potential risk of injury should be a priority to AEPs.  A potential risk when treating a client is a claim brought against a practitioner, which can lead to insurance claims. This can be a very challenging and confronting experience. Therefore, understanding how to improve the standard of client records really should be a core focus. 

Why keep detailed client records?

Continuity of service

It’s not uncommon to hear professionals say they can remember the details of their clients and any interactions with them. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of their sessions or consultations, and this has led to a poor outcome for the client. It’s therefore imperative to record details about all sessions, with specific information about what exercises were performed and how the client responded to them. It’s also important to be sure you refer to this information within the client’s record when planning future sessions.

Professional expectation

All professionals need to be aware of the various expectations placed on them, which are there to assist people to carry out their work appropriately. And it’s a common expectation that professionals keep detailed records of client interaction. This is no different for AEPs.

In the ESSA Code of Professional Conduct and Ethical Practice, it states that ESSA members and accredited professionals must ‘keep accurate, clear, respectful, up-to-date records documenting services’. This Code can be found at www.essa.org.au/Public/Professional_Standards/ESSA_Code_of_Professional_Conduct___Ethical_Practice

Defence of a complaint

If there’s any allegation of wrongdoing made against a professional, their records are going to be incredibly important. Those records provide evidence of what took place and why when providing services to clients. Without this, the professional will be relying on their memory as a defence. Information recorded at the time of the session is going to hold greater weight as a reliable defence than a professional’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for services provided and can conduct audits to be sure professionals are billing appropriately. It’s not uncommon for a professional to receive a request from a funding provider to produce records to justify their billing practices.  If the reasons behind the service, and therefore the billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many professionals ask when it comes to client record keeping is ‘how much detail do I need to record?’.  Exactly what to include can vary according to the specifics of the client’s condition and services provided. However, generally records should include, but aren’t limited to:

• Client identifying details and contact information
• Pre exercise screening information
• Date of the session
• Relevant pre exercise discussion – for example, how the is client feeling and what their expectations are
• Details of the client’s informed consent, including the risks, benefits and potential outcomes that were discussed
• Details of all exercises performed including modifications made to the program and why
• Client’s response to exercises – did they struggle, feel pain or discomfort, are they ready to progress etc
• Any instructions given to the client for exercise outside of the session provided
• Referrals to health professionals or anyone else
  

When a professional is unsure if they‘ve included enough detail, they should ask them self whether or not another professional could read the record and understand the full picture of what took place, without the need to fill in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about the client can be included, however this must be professional and only done when relevant to the service being provided. This may occur in situations where the client isn’t able to perform exercises correctly or isn’t complying with instructions when away from session, and this could lead to injuries or a lack of progression. However, it’s important to remember that client records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a professional would use when speaking to the client during a session.