Consultation sheet

Record Keeping

Records must be maintained and updated for a number of reasons.

  • They provide contact details in case you need to alter or cancel an upcoming appointment.
  • So that you can track client’s progression.
  • To record the products used and timings so you can use these at further visits and adjust the treatment plan if required.
  • Tracks any aftercare you provide the client.
  • Records patch test history.
  • As a backup in case, the client has an adverse reaction to treatment.
  • For legal reasons if the client brings a claim against you.

Client records can be stored electronically or filed away manually and should be updated at every visit. If consultation forms are not updated and do not contain a history of services and dates, then you may find your insurance invalid.

Forms should be kept for the timeframe suggested by your insurance company. This may be for up to six years.  If a client is under 21 at the time of service, then it is recommended to keep the forms for six years past their 21st birthday.

Client confidentiality must be protected at all times. Forms need to be locked away in a secure cabinet, and electronic records should be held on a password-protected computer. You may also need to register with the ICO as a data controller.

  • All information must be accurate and necessary for the service or treatment being performed.
  • Individual client records must be available for the clients to view if requested.
  • Data should not be passed on or sold without the client’s prior written permission.

The following details should be recorded on the client consultation form:

  • Personal details – name, address, contact details
  • Results of any patch tests
  • Contra-indications
  • Contra-actions
  • Reasons for the treatment
  • Any reactions to treatments/previous treatments
  • Home care advice/suggested retail items.
  • Any sales
  • Treatment timings/products used etc.
  • Next appointment or recommendations

Any contra-indications and possible contra-actions should be identified and discussed prior to the treatment. In the case of a medical referral, the therapist should keep a copy of the GP’s letter with the client’s record card.

Consultation forms must be signed and dated to prove that you have covered everything and given the correct advice and treatment plan.

Click here to access a Consultation Sheet that you can use