This documentation is also a crucial factor in health insurance processing-it helps ensure the patient will have their treatment covered by their plan. SOAP notes completed for each appointment allow your patient’s care team (which includes you!) to better understand their condition and track their progress.įor future practitioners who work with your patient, your SOAP documentation can help inform their treatment choices and enhance the patient’s continuum of care. They must be accessible should any former patient request access to the records or if the records are required for any other purpose.For providers taking appointments that are covered by patients’ insurance-such as medical massage or physical therapy-completing clinical documentation in the form of SOAP notes is a key component of the treatment process. If your business is a limited company and thus a legal entity in its own right, independent of you, you may wish to consider obtaining legal advice on how you should prepare/plan for business continuity/cessation of legal entities after the death of the natural owner of the legal entity.Īfter your death, patient records must still be stored and retained in accordance with data requirements. It is therefore important that your executors know that they will have to deal with your business as well as your personal life. If guidance changes regarding the storage of notes, then it would be your responsibility to be up to date and adhere to the guidance for as long as the notes need to be retained.Īfter death, if you are a sole trader, the patient records will become part of your estate and will be dealt with under the administration of your will or letters of administration if you have no will. Under GDPR regulations, you can only pass a patient's details on to another physiotherapist when you retire if they give explicit consent to be contacted in this way.
Once you retire, you must make suitable arrangements for storage of your patient records in order for you or your patients to be able to access them should the need arise in the future and to comply with data laws. When a sole trader or self-employed physiotherapist retires or dies, what should happen to their patient records? Self-employed physiotherapists should consider this when negotiating their contract. But having access to the records does not mean that the physiotherapist has to own the records. In these circumstances, the self-employed physiotherapist is also exposed to liability, so he/she must be able to access the records to defend him or herself. In most circumstances, the records are generated as a byproduct of the 'contract', and in the first instance, it would be the company/business owner that would be sued if something untoward happened. Therefore, it should be the company that retains the records. In this situation, the practice contracting with the self-employed physiotherapist is normally considered to 'own' the records. Where a person is self-employed but is contracted to provide services for/on behalf of a third party – for example, to a private practice or clinic, private hospital or NHS establishment – the self-employed physiotherapist is in effect working on a consultancy basis. I worked as a self-employed physiotherapist and was contracted to the owner of a local physiotherapy business. Keeping detailed records is a requirement of your CSP membership. The Data Protection Act 2018 is the UK’s implementation of the General Data Protection Regulation (GDPR).īeing able to make and maintain records is a requirement of your HCPC registration.
The use of SNOMED CT is now being driven by health policy and within NHS England its use is mandated.Your duty to share information is as important as your duty to maintain patient confidentiality ( Caldicott Review in England 2013).You must be registered with the Information Commissioner’s Office if you or your organisation keep patient records, unless a legal exemption applies.
If you use a smartphone to text or call patients, it stores their name and contact details – this counts as ‘keeping records’.
#Soap notes professional
Physiotherapy staff have a professional and legal obligation to keep an accurate record of their interaction with patients.
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