Advice from the Experts: BMS Insurance

When it comes to recalling past events, you can’t always rely on your memory. Notes are a more reliable source of truth when recalling past incidents as memory can be influenced by time and other factors. They can also be useful when managing a claim.

In this article, Scott Shelly and Ashlee Sherman of Barry Nilsson Lawyers explain why effective note-taking and record-keeping is important in the field of Pilates and how to maintain adequate clinical notes. BMS explains how detailed notes can assist with a claim.

 

What is effective note taking and why is it important?

Practicing effective note taking and maintaining adequate records is an important part of client care for Pilates instructors. Maintaining accurate and detailed clinical notes will assist a Pilates instructor if a client’s care is being transferred or to prepare any referrals to other treating practitioners. Finally, in the unfortunate event that a client makes a complaint against a Pilates instructor, having complete and accurate notes on hand is often the best defence.

Pilates instructors are generally required to practice in a manner which is competent, caring, responsible and consistent with their obligations. This extends to practicing effective notetaking by gathering and recording relevant client information in accordance with the competent application of accepted techniques and principles and includes adhering to the PAA Code of Conduct

 

General notes vs incident reports

If working with a patient, whether that be 1:1 or as part of a group, detailed clinical notes are important. These should include sufficient detail including an outline of a client’s history, Pilates program and consent obtained. Further, clinical notes should also include a record of all communication with clients.

If teaching general classes, group or 1:1, this may also include details of the students in the class and any incidents or a summary of events.

For example;

a new student attends your group Pilates class. As part of your newcomer induction, you show the student around the studio, pointing out toilets, change rooms and exits. You also introduce them to the Pilates reformer bed and explain how the springs and carriage work. Once the class begins, the new student seems to be enjoying themselves yet finding some movements challenging. As you have back-to-back classes you forget to note down the details of the student and check off that they completed the newcomer induction.

A few weeks later a claim is made as the new student claims that they have severe pain in their hips from using too heavy springs. The student claims the induction didn’t take place and that the strength of the springs was not explained to them prior to commencement of the class. As you don’t have any record of a new student attending the class or the newcomer induction occurring, you have to rely on memory about the events of the class.

 

Incident reports

Should a student or patient suffer an injury, or an incident occurs during a Pilates class, a detailed incident report should be made. This should include but not be limited to the names of those involved, dates, details of the incident, witnesses, and description of injury (if applicable). As part of managing the injury or incident, record should be kept of the cause and actions taken to resolve or mitigate the risk from reoccurring. You can refer to publications by Safe Work Australia or state-based healthcare safety agencies for more information.

 

Safeguards and tips

There are a number of safeguards which Pilates instructors can implement to help ensure they are practicing effective note taking, such as:

• ensuring that notes contain enough information needed for another Pilates instructor taking over the client’s care or if the notes were to be reviewed should a complaint be made;
• always assuming someone else (including the client) will see the notes;
• obtaining and documenting clear, complete and accurate client information;
• writing notes contemporaneously;
• if any information is retrospectively added to notes, ensuring this is clearly recorded as an amendment by noting the name of the person making the amendment and the date; and
• always detailing consent obtained from the client.

Additional safeguards for clinics to help ensure that all Pilates instructors are practicing effective note taking may include training for all new staff on note taking and professional obligations relating to effective note taking. Clinics may also consider developing and implementing note taking policies and procedures.

 

Record keeping and insurance

When facing a claim, your clinical notes or records could be useful not only in your recollection of the event, but in the handling of the claim. Detailed, contemporaneous notes can be used as evidence of what occurred and may assist in the defence of a claim. A claim can arise at any time, even several years after interaction with a client has occurred. Contemporaneous and detailed notes, as described earlier, can assist with the defence of the claim.

If unsure about an incident or if facing a claim, speak to your insurer directly for information about the claims process. As an insured PAA member with BMS, you can speak to a broker should you need assistance or to lodge a claim. Contact BMS at pilatesaa@bmsgroup.com or call 1800 940 764.

 

Barry Nilsson Lawyers communications are intended to provide commentary and general information. They should not be relied upon as legal advice. Formal legal advice should be sought in particular transactions or on matters of interest arising from this communication.

In arranging this insurance for our members, the PAA is acting as a distributor of BMS Risk Solutions Pty Ltd (BMS) AFSL 461594, ABN 45161187980.