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Importance of good record keeping

I’m sure we all keep records of our clients but I thought would be good idea to go over what information we need and why…

I visited a client of mine recently and she was delighted that I remembered about a relative of hers that had been taken ill. She had mentioned it on my last visit and she was worried about them. I had made a note on her records and so had a reminder to ask her about it on my return. It was a simple gesture but meant a lot to my client who then realises that I do care and I do listen.

I then got to thinking about other therapists and what records they keep – I spoke to one therapists who believed in not keeping records so he looks at each client with fresh eyes at each appointment. I would hope I do this to an extent but keeping records are beneficial for many more reasons than just personal ones.

Remember that all the records you obtain from your clients are personal and should therefore be kept somewhere that it will stay confidential and secure. I still keep everything on paper and in a filing cabinet but I know some therapists have found ways to keep the details on line. This is fine as long as it is in a secure place.

Basic information

Name, date of birth and contact details

This is a good start for recording data but can also be good for follow up and marketing for the future. Maybe sending cards on clients birthdays?

Past medical history

This is important to make sure there are no contra indications or any precautions you may need to take. It could also be a reason why someone has a certain posture or make you aware of an area you wont be able to change or work with.

Plan

What the client wants from the treatment – is it general relaxation or recovery from injury or reduce pain? It a good idea to get an idea of a marker post for example pain scale 0-10 to see if this improves after the treatment or series of treatments.

Or for an injury testing ranges of movement to see if this improves.

When client returns for a follow up appointment these scales can be used to keep an eye on the progress and possibly change the treatments if its not working. It is also good to remind the client how things have improved, sometimes when recovery is slow its hard for the client to keep in mind what differences have occurred.

Treatments given

This will differ depending on the treatment you are giving but it is always a good idea to make a note on what areas you worked on and what oils were used. Also note any changes that may have happened.

This is very important for when the client returns. It is great for reminding you of what you did but also if they have any complaints it is great to refer back to for reference.

Referral

Sometimes a client would need to be referred to someone else for a different style of treatment for example an osteopath or chiropractor or possibly back to their GP for more investigations. If this happens they may wish to have a copy of your notes and see what treatments they have already received. So its good to make sure they are clear and you can make sense of them.

Quite often clients will come for a massage as they have tried other things to reduce pain or stress and someone has suggested a massage – by keeping good records it makes the client feel like they are being listened to – making notes about their personal life too is nice to ask them about a holiday they were going on or how Aunt Sylvia was after her fall etc.… if things are stressing your client and you have remembered things about it they feel like they have been listened to and cared for. It all adds to the treatment and makes your client feel special.

Remember to read your past notes before seeing you client so you are ready to have a catch up and get any more information to add to the file.

Building good records will lead to better treatments and happier clients who will be happy to recommend you to others.

If you need help with forms for you clinic don’t forget BusyHive free forms can be found here.

If you have anything to add or a story to tell we would love to hear from you – either comment below or email hello@busyhive.co.uk