Why keep records?

Whatever therapy you practise, you will need to keep clear and accurate records of your activities for financial, professional and legal reasons.

What records do I need to keep?

• client records
• financial records
• training records and certificates
• insurance records and certificates
• professional membership records and certificates.

Client records

Client case history sheets

You will need to devise your own best way of keeping your client records. Most therapists use some form of pre-printed client case history sheet or a computer-based equivalent. This document will act as a complete record of the client’s contact, personal and medical details, and will be used to detail the treatment that the client receives each time they attend for a session – see the example on page 103 (Figure 16).

You may need to include further details on your client case history sheet, but this will depend on the work you are engaged in and the need to comply with any legal, insurance or professional requirements related to your practice.

Keeping client contact details

Whatever system you adopt for recording your client contact details, try to keep it as simple as possible. Aim to minimise the number of times you have to record the same details, for example by limiting the number of places in which you store your clients’ contact details to no more than two places – such as stored on your phone and on your client’s case history sheet. Keeping these details in a maximum of two places will cut down on any updating time and should mean that you will be less likely to forget to update all the contact records.

Keeping client treatment records

If you always work from home then you will be able to keep all your client records together either in your filing cabinet, if you keep paper copies, or on your computer. However, if you work from two or more locations, work from your clients’ homes or have a totally mobile practice, you will need to keep your client data in a way that you can easily carry it around with you. This could mean that you will find it more efficient to keep your client case history records on your laptop computer, and also store their contact details on your mobile phone so that you can make any quick calls whilst travelling or when working from different locations.

What should I include in my client treatment records?

When you record your client sessions you should include an overview of your client treatment plan, and any particular techniques that you used, or supplements or herbs you may have prescribed. You may also find it helpful to document your clients’ responses or outline their possible future needs or how their treatment could be developed. This will, of course, differ according to the therapy you are practising.

Client records – the golden rules

The key points you should take note of are:

• All your records should be factual and accurately record your session with your client – including the details of any treatments and responses. You should also include the date (and if appropriate, the time) of the session.
• Your records should be easily legible, either typed or handwritten in ink and not pencil – this is so that none of your notes can be erased.
• You should include full details of your client’s treatment plan i.e. what issues did the client present with? What treatment did you give? What follow-up work do you intend? Document any decisions which were made and whether any information was shared with others.
• If you have had any contact with the client in between sessions, for example phone calls, emails or letters – make sure you write these up or include a copy of the correspondence and your response in the client’s file.
• If you use abbreviations, you should make sure that these are consistent – and if you have your own form of abbreviating certain words or statements make sure you include a breakdown of what these are describing.
• Don’t include any comments which are speculative rather than factual, or which could be taken to be offensive.
• Any mistakes in your handwritten notes should be crossed out – don’t use Tippex to mask the mistake.
• Try to get into the good habit of allowing time at the end of each session to write up your notes as soon as the client has left.
• You should also keep copies of your diaries or appointment records. Make a note beside each entry as to whether the appointment was kept. If the appointment was cancelled, make a note of the reason for the cancellation.

If you are still in any doubt as to the degree of detail you need to keep, you might like to raise this matter with your training school or tutor. I usually work to the worst case scenario – if I had to present in court the details of my contact with a client, how useful and efficient are the details I have recorded? I generally find that this helps to focus my mind appropriately – effectively preventing me from recording extraneous information, or recording anything that I wouldn’t want the client to read or become public knowledge.

Keeping your client records safe and secure

If you keep a paper-based client record system, you should make sure that all documents are kept locked away in a metal filing cabinet when not in use. If your records are kept on computer, then you should ensure that access to all records is password protected, and that the records themselves are encrypted. You should also get into the habit of using a password protected screensaver so that if you have your computer running while you leave the room for a few moments when you have a client in the room, you can switch the screensaver on and protect your clients’ files from being viewed or tampered with by any other person.

If you keep your records on computer you should get into a regular routine of ‘good housekeeping’ as soon as possible. This means:

• creating directory and file structures that are relevant to your work
• creating backups of all your files
• creating an archive for your client records which are no longer active
• clearing down your emails and filing any emailed client correspondence appropriately.

You should create a backup of all your files on at least a weekly basis, and keep the backups for the previous three weeks in case any of your data did not transfer correctly or has since become damaged or corrupted. You may find it more useful to keep client records which are no longer active within an ‘archive’ on your computer instead of relying on CDs or floppy disks for storage in order to save any problems in respect of physical storage, the potential for mistakenly overwriting files, the usual problems inherent in data transfer and, depending on how the CDs or floppies are stored, the potential for damaged or corrupted data.

How long do I need to keep my client records?

This is a difficult question to answer with total authority as there is no legal requirement to keep your client records for a defined period of time. Insurance companies will advise that these records should be kept for as long as you possibly can because of the potential of a claim being made against you even if it is several years since you treated the claimant. Therefore you should keep these records for long as it is practicable for you to do so.

Data Protection Act (DPA)

The Data Protection Act 1998 requires anyone who processes personal data to register with the Information Commissioner as a data controller unless they are exempt. Failure to notify is a criminal offence. Under the terms of this Act a data controller is taken to be anyone who decides the purposes for which any personal data is processed and the manner in which it is processed. And personal data is taken to mean any data which relates to a living individual who can be identified from that data and any other information which may be in the possession of the data controller.

The principles of data protection state that anyone processing personal data must ensure that the data is:

• fairly and lawfully processed
• processed for limited purposes
• adequate, relevant and not excessive
• accurate
• not kept longer than necessary
• processed in accordance with the data subject’s rights
• secure
• not transferred to countries without adequate protection.

This Act gives clients the right to view their case history records. If a client wants to see their records, they must request this in writing. You will then have a maximum of 40 days in which to respond to this request. For further information about the DPA, see Chapter 12. Most complementary therapists are not required to notify any manual records, however you can choose to notify them voluntarily. If you store your records or process your personal data on a computer, laptop or palmtop device, you will need to register. Registration currently costs £35 per year (no VAT), and you can register over the internet or by phone. The DPA website contains a handy on-line questionnaire which you can work through to assess whether or not you need to register.

Financial records

Keeping records of your income and expenditure

Whatever methods you use for your financial record-keeping you will need to be able to prove your business income and expenditure. This means that even if your accounts are kept on computer, you will still need to keep physical copies of any receipts, bills, statements or invoices you have received.

You can set up systems for this quite simply. In order to prove your income you will need to be able to present a receipt or invoice for every payment you have received. This means issuing receipts to clients for each session and keeping a copy, and also keeping a copy of any invoices you have raised to companies or individuals in respect of your services. The simplest method of keeping track of your receipts is to use a duplicate book. You can then quickly issue a receipt for each payment you receive and automatically have a duplicate entry to tie in with your records.

You will then need a system for keeping all your receipts and bills etc. A simple system, and a good routine to get into is to put all your receipts, bills, invoices and statements into a box file, which you have set aside for this purpose, at the end of each working day. This will enable you to quickly sort through all the documents at the end of the week in order to enter these details into your accounts and file the documents accordingly. Make sure that you keep your box file locked away in your filing cabinet when you are not working on your documents. For further details about keeping accounts and using spreadsheets, see Chapter 5.

How long do I need to keep these records?

You will need to keep copies of all your financial records for at least six years – this is the current year plus the five years prior to the latest date for returning your tax return – this a legal requirement.

Training records

You will need to keep records of all your training, no matter what form this has taken, so that you can prove how much time you have spent being trained, or what activities you have been engaged in that will add credits towards your continued professional development (CPD). Each organisation you are a member of will have its own criteria for activities which count towards your CPD total and will also determine how many credits or hours you need to complete each year – you will need to comply with this in order to maintain your membership.

Keeping your training records

All you need for keeping your training records is an A4 ring binder and some plastic pockets to keep your paperwork in. As most training courses will now provide you with a certificate of attendance, or if you have gone for a more in-depth training course a certificate detailing your new qualifications, it makes more sense to keep your training records in a paper-based system.

Depending on the amount of training you do in any one year, you might want to keep each year’s training in a separate ring binder for ease of use. Keep a summary of your training for the year in the front of the binder. You can keep this in a simple log format as detailed below (Figure 17).

You may find it helpful to include a note of the minimum number of credits, or hours spent in training, that you will need to have completed in order to comply with membership requirements.

How long do I need to keep these records?

It’s a good idea to keep these records for the entirety of your career as a complementary therapist. Whenever you change your professional membership from one organisation to another, you will need to be able to confirm all the dates of the training you have undertaken, the subjects or areas you have trained in and also be able to produce any certificates or qualifications that you may have received.

Insurance records

You will need to keep records of any contact you have had with your insurance company or brokers, as well as details of any insurance claims you may have made or may have been made against you along with copies of all your policies, certificates and any endorsements.

Keeping your insurance records

It is often easier to keep these records in a paper-based system, otherwise you are likely to end up with a mixture of paper and computer files. You might find it helpful to keep all your insurance correspondence and certificates for each financial year together in one ring binder. Copies of your policies and any endorsement details will usually remain in force unless they have been amended in some way (in which case you will be sent new copies), and therefore should continue to be filed with your current year’s documents until any such changes are made. Any details relating to claims made by clients might be more appropriately filed in with your client’s case history records. All your insurance records should be kept in a locked filing cabinet.

How long do I need to keep these records?

There is no legal requirement to keep these documents for a specified period of time, however it is good practice to keep these records for as long as you possibly can in case a claim is made against you.

Professional membership records and certificates

You will need to keep details of any professional memberships you hold, copies of any correspondence you have had regarding your membership and any certificates confirming your membership and the designations you are permitted to use after your name.

Keeping your membership records

It is generally simpler to keep all these records together in a paper-based system. As you are unlikely to have much in the way of any correspondence to keep, and your membership certificates are usually current for as long as you are a fully paid-up member of that organisation, you may find that if you review all your documents on a regular basis you can keep everything in just one file.

How long do I need to keep these records?

You will need to keep these records for at least as long as you are a member of a particular organisation. You may find it helpful to keep these records for the entirety of your career, for example, for biographical or CV purposes.

Keeping, storing and disposing of records

Keeping your records

The length of time that you need to keep your records for will vary according to the type of record and whether there is a legal requirement to store certain records for a particular length of time. Unless you have been advised by a professional on the length of time to keep a particular set of records, the usual requirements are:

• client records: no legally determined storage time – keep indefinitely, or for as long as is practicable
• financial records: legal requirement to keep records of your accounts for at least five years prior to the latest date for returning your tax return
• training records: no legally determined storage time – keep for duration of your career
• insurance records: no legally determined storage time – keep indefinitely, or for as long as is practicable
• membership records: no legally determined storage time – keep for duration of your career.

Storing your records safely

Paper records should always be kept locked away in a metal filing cabinet when not in use, as should any floppy disks or CDs. Any computer-based records should be password protected and computer files should be encrypted. You should take regular backups of all your computer files, at the very least on a weekly basis. And if your computer system is the main store for your records and the means by which you process all your data, you should also ensure that you keep a copy of the registration details for any software that you have bought and the registration keys for any shareware that you have purchased. For more information about encryption software, see Chapter 12.

Disposing of your records safely

You should ensure that you dispose of your records in a safe and secure way. For security reasons your:

• paper records should be shredded
• CDs should be shredded or snapped in half
• floppy disks or hard drives should have a low-level erasure applied to them (for further information on how to do this, consult the manual for your operating system).