Record keeping for Soft Tissue Therapists

Why do my records matter?

Good record keeping supports continuity of care, backs up the pre-treatment information you gave, and reinforces any post treatment advice you provided. 

They also help protect you and your clients. If there’s ever a complaint or claim, your treatment notes can form an important part of the evidence. They show that the treatment took place, how you assessed suitability, your clinical reasoning, what was discussed, and why you made each decision.

What to record

You should follow your training and best practice guidelines.

As a practical guide you should look to record the following information:

• Details of any pre-treatment/session consultation including the presenting issue, relevant medical conditions, medications, allergies and contraindications.
• Suitability assessment and whether informed consent has been taken (and how).
• Treatment plan and adjustments planned activity and techniques and whether any modifications or adjustments are being made to ensure suitability.
• You should look to include the rationale for any decisions made. This should include a record of any pre or post session information provided.
• Session details, include date/appointment times, client responses, outcomes or details of any adverse events.
• Testing and safeguarding evidence of patch testing where appropriate if creams were used.

How long to keep records

You must keep your records as follows in order to comply with the Balens insurance policy:

• For treatment with adults a minimum of 7 years
• For treatment with minors, for 7 years after they turn 18.
• Vulnerable adults: consider retaining records beyond 7 years, as limitation periods may be extended by the courts.

Data protection law generally requires that records are kept for ‘no longer than necessary’, although the exact time is not specified and depends on your circumstances. Records may be kept where this is necessary for the establishment, exercise or defence of legal claims. If you are unsure, seek appropriate legal or professional advice.

Who owns the notes? Who can see them?

• Ownership: in many settings, patient records are the practitioner’s property-even if you move practice, refer the client on, or supervise a student under your insurance (in which case, the records are yours).
• Where you are working in a clinic or as part of a multi-disciplinary team, it is important you keep individual client records or can ensure access in the event of a claim.
• Clients may also have rights to access their personal data under data protection law.

If you move, sell, or stop practising

You must ensure you have ongoing access to your treatment records for insurance and professional purposes. This may also be important in the event of illness/incapacity (e.g., via a Will or Power of Attorney).

Record keeping in action – claim experience

Example 1 – Treatment despite a contraindication

A client books a sports massage for shoulder pain. During the consultation, they mention they have recently started taking anticoagulant medication following surgery. After assessing the information, the therapist explains that deep tissue techniques over certain areas would not be appropriate and modifies the treatment accordingly, using lighter techniques instead.
Several weeks later, the client questions why they did not receive the treatment they had expected and alleges that the therapist failed to provide the service they had booked.

The treatment records demonstrate that:

• A full consultation and medical history were completed before treatment.
• The client disclosed they were taking anticoagulant medication.
• The therapist identified the increased risk of bruising and adapted the treatment accordingly.
• The reasons for modifying the treatment were explained to the client and consent was obtained before proceeding.
• The techniques used and the advice given after treatment were recorded.

These records provide evidence that the therapist exercised appropriate clinical judgement and prioritised the client's safety.

Example 2 – Post-treatment soreness

A client attends for a deep tissue massage to address long-standing tension in their upper back and neck. A few days later, they complain of soreness and claim the therapist used excessive pressure without warning them of the possible effects.

The therapist's treatment notes show that:

• The client's goals and expectations were discussed before treatment.
• A suitable assessment was carried out and no contraindications were identified.
• The client requested a firm pressure and confirmed they were comfortable throughout the session.
• The areas treated and techniques used were documented.
• The client's feedback during treatment was recorded, including pressure checks made throughout the session.
• Aftercare advice was provided, including information that mild soreness may occur for 24–48 hours following deep tissue treatment, together with advice on hydration, gentle movement and when to seek medical advice if symptoms were unusual or prolonged.

The records demonstrate that appropriate assessment, communication, consent and aftercare formed part of the treatment, helping to evidence that the therapist acted in accordance with accepted professional practice.