Accurate and timely clinical documentation (‘notes’) is one of the most important safeguards in physiotherapy practice. 

It protects patients, shows clinical reasoning, provides evidence to justify treatment decisions and allows us to demonstrate that we adhere to our ethical and professional obligations. 

Quality clinical documentation that adheres to professional standards also minimises risks of a costly and protracted conflict in the case of an insurance claim. 

A case example 

The value of quality clinical documentation is illustrated in the case of Fischer v Brown [2021] VCC 104, in which the County Court of Victoria preferred the contemporaneous medical records of the treating clinician over the patient’s recollection of advice given prior to surgery. 

As described by Polaris Lawyers in ‘Your word against the doctor’s: medical negligence cases and the accuracy of medical records’, ‘The case centred around a factual dispute between Ms Fischer and Mr Brown about what was said and done before and after’ a surgical procedurethat was later complicated by postoperative wound breakdown.

‘Ms Fischer alleged that she remembers Mr Brown advising her to try to cut down her smoking before the surgery to four or five cigarettes per day. 

The medical records supported Mr Brown’s evidence that he advised her to stop smoking for six weeks before the surgery’, that he provided her with written resources to support that, ‘and that he warned her specifically of the risks of continued smoking and impaired wound healing’. 

As a result, ‘Ms Fischer was unsuccessful in her medical negligence claim’. 

The Court confirmed that it is generally ‘very slow to disregard medical records made at or soon after’ treatment, because a health practitioner making records at the time has no motive other than noting what was said and done. 

Accuracy and timeliness matter 

Accurate documentation reflects what actually occurred during the clinical interaction. 

This includes subjective reports, objective findings, treatment provided, patient education, informed consent and plans for follow-up. 

Accurate notes help to demonstrate that risks were identified and managed and that care was clinically reasoned and met expected professional standards. 

Repetition, errors, vague descriptions or information gaps can undermine the credibility of the entire record. 

Recording information as close as possible to the time of service ensures that details are captured while they are still fresh. 

This reduces the likelihood of omissions, inconsistencies or inaccurate retrospective reconstruction of events.

Missing information and inconsistencies can later be interpreted as negligence or dishonesty. 

Timely notes also support safe continuity of care when other clinicians rely on detailed and up-to-date information to make safe decisions, such as awareness of precautions and making appropriate treatment progressions. 

Your notes are your best defence 

Legal personnel and investigating regulators rely heavily on written evidence in cases of claims or complaints. 

Insurers consistently report that well-kept clinical records are the strongest defence against claims, even when outcomes are poor or complications occur. 

As evidence, they may be your only defence when claims arise years down the track, long after the clinical interaction is forgotten. 

When a patient alleges harm, whether physical, financial or related to professional conduct, the insurer’s first step is to request the clinical file. 

The file becomes the primary evidence of: 

• what the physiotherapist assessed
• what risks were identified
• what treatment was provided
• what informed consent was obtained
• how the patient responded over time. 

When these critical elements are absent, the balance of probability shifts toward the complainant’s version of events, even when the physiotherapist recalls acting appropriately. 

How inadequate records escalate a claim 

The legal question of whether a failure to document constitutes negligence has not been fully tested. 

However, it is well established that poor notes can carry significant professional and evidentiary consequences. 

Several factors make poor documentation particularly damaging in indemnity claims and regulatory complaints: 

• missing consent weakens defence
• retrospective reconstruction is viewed as unreliable
• scant, generic or templated notes undermine credibility
• inconsistencies suggest carelessness. 

There is a well-recognised legal presumption – ‘if it isn’t written down, it didn’t happen’. 

In practice, this means that gaps in documentation are rarely interpreted in a clinician’s favour. In a complaint, audit or claim, your clinical record is often the most influential source of evidence about what you observed, what you decided, what you explained and what the patient agreed to. 

A few words on consent 

‘Ensuring informed consent is properly obtained is a legal, ethical and professional requirement on the part of all treating health professionals and supports person-centred Care’ (Australian Commission on Safety and Quality in Health Care). 

Any healthcare treatment requires valid consent, either verbally, written or implied. 

The foundational Australian authority is Rogers v Whitaker (1992) 175 CLR 479, which established the duty to disclose material risks – those to which a reasonable patient would attach significance or which the practitioner knows this patient would consider significant. 

Consent to care should be obtained prior to assessment and treatment and revisited whenever the plan changes, new risks emerge or a patient expresses uncertainty. 

A documented record of explanations and patient consent is the only reliable evidence that a clinician has attended to their duty of care on this matter. 

It is not practical to document consent for every moment of the clinical interaction. 

However, you can reduce your risk of a complaint or claim if you make consent practical and visible: explain what you are going to do before you do it, especially where touch is involved. 

Unexplained touch can reasonably turn into a boundary violation or sexual misconduct claim. 

Confirm that the patient is comfortable to proceed and respond if the patient hesitates. 

For further detail on consent in the healthcare setting, see the Australian Commission on Safety and Quality in Health Care’s Informed consent in health care fact sheet and the APA’s risk mitigation resources (eg, ‘Patient-centred care starts with consent’). 

What about AI? 

AI tools can summarise conversations, generate SOAP notes and autopopulate treatment descriptions. 

This can be helpful for reducing cognitive load and freeing up time for patient care. 

But these tools rely on patterns, not clinical reasoning, and they cannot independently verify accuracy. 

Ahpra published formal guidance in 2024, titled ‘Meeting your professional obligations when using artificial intelligence in healthcare’. 

Key elements include the fact that practitioners are expected to inform patients and clients about their use of AI and consider any concerns raised. 

They must also check that patient data is collected, stored, used and disclosed in accordance with legal requirements and be aware of whether patient data is used to retrain the AI model. 

Risks of AI-generated notes include: 

• false completeness – AI-generated notes may appear polished but omit key details such as red-flag screening, consent discussions or nuanced patient responses generic phrasing – notes may become repetitive or vague, which could be interpreted as inappropriate or nonindividualised care 
• inaccurate assumptions – if the AI infers details that were not explicitly stated, the record may misrepresent the session 
• reduced clinician engagement – overreliance on automation can erode the human attributes of active reflection and evidencebased, individualised clinical justification
• failure to review and correct while details are still clear – the obligation is not just to review AI output at some point but to verify every AI-generated statement against source documentation and clinical observation before the note is finalised and to do so in a timely manner; reviewing AI-generated notes after a delay or failing to review them at all allows inaccuracies to become part of the permanent record. 

How long should clinical notes be retained? 

Requirements for retaining records after an episode of care vary by jurisdiction and you should comply with the health records legislation in the state or territory where you are practising. 

In general, Australian legislation prescribes minimum retention periods. 

For adults, records must be kept for a minimum of seven years from the date of the last contact. 

For children, it is until the child reaches 25 years of age. 

In practice, you should retain records well beyond the seven-year minimum if there is any prospect of litigation or complaint. 

The take-home message 

Write good notes. 

Accurate, timely documentation is a patient safety tool and a professional safeguard. 

Poor quality documentation risks patient safety and can turn an otherwise defensible clinical interaction into a costly and protracted claim. 

Case examples 

When physiotherapy notes are good, they demonstrate quality care and protect you.  

Case 1: A physiotherapist provided routine treatment following total knee replacement. 

The patient progressed well with range of motion, strength and mobility and was discharged. 

The patient later developed myositis ossificans and claimed that this was caused by ‘aggressive physiotherapy’. 

The physiotherapist had little to no recall of treating the patient but the notes written at the time followed the SOAP (subjective, objective, assessment, plan) format and clearly detailed the care provided including specific exercises, number of repetitions, mobility progression and measures of range and strength. 

The notes were assessed as comprehensive and clear and supported the argument that appropriate care was provided. 

No further questions were asked of the physiotherapist. 

Case 2: A patient was seen by a physiotherapist for back pain that had been ongoing for more than 25 years. 

The patient later alleged that during the assessment, the physiotherapist had pressed on his back, causing pain, and that in the days following the consultation, he became unable to walk because his hips and legs had ‘let go’. 

The physiotherapist’s notes included informed consent to subjective and physical assessment, review of the relevant medical imaging, screening for serious pathology and factors that would necessitate a careful assessment such as steroid use (possible bone fragility) and note of a high daily morphine equivalent dose (for consideration of possible pain sensitisation and/or cognitive effects). 

While there were conflicting versions of the amount of pressure applied to the patient’s spine, it was concluded, based on the clinical notes, that the physiotherapist’s examination was necessary and appropriate, that it was conducted with due care and that her techniques were considered in that she amended her approach, taking into account the patient’s presentation and history. 

There was insufficient evidence that the physiotherapist’s performance was below the required standard and the case was closed with no further action. 

Case 3: A patient alleged a leg injury following a group exercise class. 

The concern was raised two years after the class and the physiotherapist’s contemporaneous notes became central to resolving a factual dispute. 

The notes recorded that the patient reported no pain during the exercise component, experienced no adverse incident or response and reported feeling well when leaving after the exercise class and following the education session. 

The notes also documented routine education that delayed-onset muscle soreness may occur after exercise as well as education that during the exercise class the patient could stop or reduce exercise intensity at any time. 

The following week, the patient described left thigh soreness for two to three days following the first exercise class. 

An assessment was performed and recorded in the notes, with findings consistent with muscular soreness and no joint involvement. 

Approximately two years later, the patient complained of right hip pain and attributed it to the exercise class. 

The original record – including the absence of symptoms on the day, the absence of any event or injury in the class, the documented education and the explanation of risks, consent and self-management options – helped clarify what occurred at the time and supported the insurer’s position.

When physiotherapy notes are poor, it becomes harder to demonstrate safe, quality care. 

Case 4: A patient was diagnosed with a thoracic fracture after seeing a physiotherapist for management of thoracic pain. 

The treatment provided included manual spinal mobilisation techniques. 

On review of the clinical notes, it was identified that the physiotherapist did not record medical history, screen for red flags or precautions to treatment, explain why mobilisations were indicated or obtain informed consent to assessment and intervention. 

Even if the fracture wasn’t related to treatment, the notes failed to show that the physiotherapist considered the patient’s risk profile or willingness to undergo treatment. 

Case 5: A patient who was seeing a physiotherapist following surgical rotator cuff repair reported catching sensations in the operative shoulder during treatment. 

The physiotherapist continued to progress the load in the patient’s exercise program. 

The patient later experienced acute shoulder pain and a repeat scan showed that the repair was re-torn. 

The patient lodged a negligence claim against the physiotherapist. 

On review of the physiotherapist’s notes, there was no record of the reported catching sensations even though the physiotherapist recalled that the patient described them. 

The notes also lacked information on baseline measurements, informed consent, exercise details, education provided and evidence to justify the exercise progressions. 

Case 6: A patient attending physiotherapy for postoperative knee rehabilitation saw multiple clinicians in the same practice.

One physiotherapist failed to document that the patient required close supervision during balance training. 

At the next visit, another clinician progressed the exercises, unaware of the patient’s ability during the previous session. 

The patient fell and injured their wrist. 

The patient’s family made a complaint and a claim was lodged. 

The incomplete documentation was central to the claim.

Resources and further information 

APA Guidelines for writing clinical notes 

‘Risks and benefits of AI in note-taking’, InMotion 

‘Informed consent in the age of AI’, InMotion 

Ahpra Managing health records – self-reflective tool Managing health records – summary of obligations  

The Australian Commission on Safety and Quality in Health Care Informed consent in health care fact sheet