Physiotherapists are increasingly relying on artificial intelligence (AI) as a tool to handle vast amounts of information, including client records. 

While the use of AI for note-taking and record keeping offers many benefits, there are limitations and risks that physiotherapists need to consider.

Professional obligations

The Physiotherapy Board of Australia’s shared Code of conduct includes several obligations for physiotherapists to maintain clear
and accurate health records to ensure clients receive high-quality care. 

These obligations include various requirements to ensure that physiotherapists are taking clear and accurate health records.

Effective note-taking corresponds to notes that are visually clear, concise, organised and structured. All the relevant information
should be readily identifiable to enable a different physiotherapist to assume the client’s care. 

Your notes should include informed consent, information about a client’s relevant medical history, the purpose of the consultation and the procedures or exercises you will perform, for example. 

Remember that your notes could constitute evidence when defending a claim.

The risks and benefits of AI

The benefits of using AI to document client records may include increased accuracy, efficiency, organisation, accessibility and cost
savings. 

AI can assist during consultations to create a record of the information automatically, including client history, presenting
complaint and management. 

This provides fast data collection and reduces the need for a physiotherapist to take down their notes manually, often resulting in improved care provided to clients.

However, there are limitations to AI that physiotherapists need to consider. 

These include, but are not limited to, the implementation of the AI software, obtaining informed consent and securing the privacy of their client’s records.

Implementation of AI

The use of AI relies on the appropriate integration of the software into the physiotherapist’s clinical routine or their clinic’s system. 

To ensure suitable incorporation, it is also imperative that there are pertinent safeguards in place regarding the use of AI.

One such safeguard is to ensure that the physiotherapist understands enough about the AI implementation to use it safely
and meet their professional obligations. 

Physiotherapists and their staff should obtain relevant training in the use of the AI in their clinical records system in order to understand how it works and what it does and does not do.

Physiotherapy clinics should also develop policies and procedures for the use of AI to ensure appropriate use of the software, in
accordance with the clinic’s professional obligations.

Informed consent

A physiotherapist is required to inform clients about the use of AI and to consider any concerns raised by the client. Clients’ consent for the use of AI is critical and physiotherapists must document it in their records. 

There is a risk that a client may not consent to the use of AI to record their information; accordingly, a physiotherapist will still be required to manually record client information.

Physiotherapists are encouraged to review their informed consent obligations under the shared Code of conduct.

Client privacy

Physiotherapists are also required to ensure their use is compliant with privacy legislation. 

This involves understanding whether the use of AI in their practice may result in the storage or use of the client’s personal and health information by the AI tool provider.

Physiotherapists are encouraged to carefully review the terms of use for an AI tool and to consider their professional and legal obligations regarding their client’s information. 

This may require revision to privacy policies, consent processes and other procedures. 

The Office of the Australian Information Commissioner has provided a guide to health privacy, which contains useful information regarding compliance with privacy obligations.

Other considerations

While AI can be a useful tool for note-taking, physiotherapists are still required to review the records taken by any AI software
to confirm the contents are accurate. 

Physiotherapists should only sign or approve the records generated by AI once they have reviewed and verified that the notes are complete and accurate.

The use of AI does not relieve a physiotherapist of their professional obligations and may pose risks if the information is not accurate.

Therefore, the implementation and use of AI need to be carefully considered to ensure that the risks are managed appropriately.

Notes for mitigating risk

Whether you choose to manage your notes manually or implement AI, it is important to consider your professional and legal obligations as well as the potential risks and benefits mentioned above.

For physiotherapists, clinical notes and records can be invaluable for providing effective care and can provide useful information that could assist in your defence if you face a claim or complaint.

Should you face a claim or incident, speak to your insurer directly for information about the claims process. If you are part of the APA Member Insurance Program, BMS can assist you. Speak to a BMS broker on 1800 931 068 or complete and submit the relevant claim form in the BMS portal.

This article is facilitated by BMS, with information on AI in note-taking and your professional obligations by Scott Shelly and Alexander Sheridan of Barry Nilsson. BMS covers how notes and records could assist in the event of a claim.

Disclaimer: You must be a current APA member to be eligible for the APA member insurance program. You must be part of the APA member insurance program in order to access additional cover. If your membership ceases you will not be offered renewal when your policy expires. In arranging this insurance for our members, APA is acting as a distributor of BMS Risk Solutions Pty Ltd (BMS) AFSL 461594, ABN 45161187980. This insurance is issued by BMS under a binder with Certain Underwriters at Lloyd’s. When acting under a binder BMS is acting as agent for the insurer and not as your agent. This is general advice only and BMS has not considered whether it is suitable for your particular objectives, needs or financial situation. Please read the Policy Wording and the BMS Terms of Engagement, which contains the Financial Services Guide, before making a decision about purchasing this policy. APA may receive a percentage of the commission paid to BMS by the insurer and/or a fee per policy.