Treatment usually begins with a consultation during which the practitioner asks the client a series of questions about how they are feeling, medical history and why they have requested this treatment. This is an opportunity for the therapist to ensure that there are no reasons why it would not be advisable for the client to have the treatment, ruling out any contraindications.
It is essential that you keep fully detailed client records for every single client you have. Client Record Cards/Consultation Forms should be completed on every visit the client makes to you. On their first visit, you will need to have a full consultation to ascertain if the client has any problems, and following the consultation, when you have fully recorded the details, you need to ask your client to sign and date the form to confirm that the details given are correct.
Following this, on each visit that the client makes to you, you should mark on the rear of the form the date of the visit, what the treatment undertaken was, and ask the client to sign the form to say that he/she is happy with the treatment.
DO NOT WRITE IN THE DATE FOR THE CLIENT IN ORDER TO SAVE TIME. If the client decides to sue you, you will only be covered by your insurance if the client has written in the date themselves.
It is essential that you keep these records because should there be a problem or complaint after the treatment, this information is your first line of defence – not only with the client, but also your insurance provider.
A sample form is attached, for your information, but you could design your own form to suit your requirements.
It is also advisable to get before and after photographs of every client for insurance purposes and marketing.