From a therapist development point of view, notes help you track your client's progress, ensure their safety, and maintain professionalism, thus you should ensure that your notes contain sufficient detail including an outline of a client’s history, diagnosis, assessment, treatment options, treatment plan, consent obtained, and any treatment provided. They serve as a record of your professional practice and may be important in the event of any disputes or questions about the treatment provided.

Failing to maintain adequate clinical notes may amount to a breach of professional standards as well as those required by relevant health funds if offering a rebate, and audits do happen so it’s best to be prepared.

So what is the best way to take effective notes:

• ensure that notes are clear enough so that another practitioner could easily take over the client’s care if required.
• always assume someone else (including the client) will see the notes.
• obtain and document clear, complete and accurate client information.
• write notes as soon as close to your client’s visit as possible.
• always detail consent obtained from the client and ensure Consultation forms are attached to the client’s record (electronic or hard copy).

Information to include:

• Client's name, date of the session, and any relevant contact information.
• Use the SOAP (Subjective, Objective, Assessment, Plan) or DAP (Data, Assessment, Plan) format as these are both commonly used for healthcare and therapy notes within Australia. Revisit your own study notes on how to write these types of notes if it has been a while.
• Be Specific and Clear: Use specific language to describe the client's condition, including muscle groups and location of pain or tension.
• Mention the techniques you used and their effects.
• Describe any improvements or changes observed during the session.
• Include Client Feedback and outcome of session
• Stick to factual, objective information and avoid personal opinions or judgments.
• Use Professional Language.
• Organize and Store Notes Securely: observe privacy and confidentiality requirements.
• Periodically review and update your notes as your client's condition and treatment plan evolve.

And remember your Association is here to help should you need it!