How to Protect Ourselves as a Health Provider By Documentation

We recently finished another round of the increasingly popular Physiopedia Volunteer Orientation Course. As part of the final assignment members were tasked to write an original piece of work to share with the profession, the contributions were of the highest quality. Below is the great piece of work written by Ronald Yip.

We all know, as a physiotherapist, we love every step of assessing a patient, analyzing problems, giving a diagnosis and treating the impairments but one – doing progress note.

Documentation can be the most annoyingly time-consuming process and I found a lot of my colleagues considerate as useless legal requirement. But, is it?

According to Australian Health Practitioner Regulation Agency, they received a total of 9,338 notifications between 2018 and 2019. It is a frightening number considering roughly 25.5 practitioners were being investigated per day.

This is exactly why it is important to record your treatment accurately. It would serve its great purpose to provide evidence that quality care was provided by competent therapist. Hence, I am searching for what investigators look for when they are gathering evidence and how to provide them with the information they want when writing up my notes.

Here, I come across the FACT method.

F – Fact

This is the basic of doing up a progress note for any patient. We must accurately jot down factual event during your assessment and treatment. But what is factual event?

Let’s judge it yourself.

  1. Client A appears to be agitated and unsettled; or
  2. Clients A is unable to sit at his chair with verbal and physical prompt. He becomes verbally aggressive to staff, swearing and using sexually inappropriate phrases.

It is very clear which one is more preferable. When documenting fact, it is always better to write down what was seen, heart, smelt or touched. This also avoided different interpretation of an adjective when another person is reading your note.

A – Action

What are the actions taken by you, your clients or other staff. You identified problems using your five sense and assessment skills, then what you have done to achieve goals. It might be easily done by noting your treatment method. But when incident happens, investigator is not interested in your treatment preference but instead if you have done anything to prevent harm.

It comes in handy if you have a written consent prior to the first session and before you use any special treatment techniques, such as dry needling and cupping.

Additionally, when there is adverse reaction on your patient, what action was taken by yourself and other staff to rectify of minimizing harm.

C – Communication

This can be one of your actions to show as evidence that you prevented harm. It is also a way to transfer from or share risk with yourself to another staff, patient or family.

This can be communication between yourself and another staff member through handing over information. Now, you are transferring the responsibility to the staff member if you have kept a clear document.

It could also be your explanation to clients and family, advising the risks of certain treatment methods. This is good way to show that patients are giving an informed consent to whatever you are doing on them which clear you from liability.

T – Time

Quite self-explanatory, the time of your action and communication. I use FACT method to make sure I have all elements I need to defend myself in case of a complaint. In fact, I find that it is also a systematic and efficient way of documentation. I hope this will change your thought towards note taking and will be your preference method in the future.


It has been a very interesting 4 weeks which makes me feel like a student again. Since being a qualified physiotherapist, I seldom look back to my lecture notes from University. Joining PP gives me an excuse to review topic that I love but not normally use in my current practice. Interestingly, I also see a different perspective when looking a topics that I learnt as a student.

After leaving the university, I never thought I would need to use my evidence searching skills until 4 weeks ago. I think joining PP gives me incentive to learn and touch on latest available evidence, which helps me to decide my assessment and treatment when practicing.

PP is also a great platform for physiotherapist around to globe to share our knowledge. I love how people who I have never met in person, but carrying the same value as making physiotherapy more accessible to work together.

It is not easy to complete PP workload on top of real-life practice, but I still enjoy every bit of participation. I hope I will be able to continue contributing to this community and make physiotherapy stronger.