APA Guidelines for Writing Clinical Notes
Every one of our client’s story is different. When it comes to capturing these stories, we all want to write and read good clinical notes - safeguards that protect our clients, peers and ourselves and evidence that demonstrates our quality care. We all want a locum or a colleague to be able to understand our client’s story and we all want to meet the accountabilities that arise.
Writing clinical notes is an integral part of daily practice for physiotherapists; from students and new graduates, to experienced physiotherapists, across a variety of practice fields, work place settings, and complex and changing environments. The challenge in writing good notes is knowing what the key inclusions are and creating the systems and disciplines to ensure that process occurs reliably.
The foundations of good practice
Our guidelines for writing clinical notes support safe, competent and accountable practice and help our members maintain the good standing and autonomy of the physiotherapy profession.
The guidelines intend to illustrate the foundations of how we think critically about what we write in our notes, rather than following a set of rules. In this way, the material is applicable for all members and references general, rather than specific, areas of practice.
The guidelines and support materials will develop with time. We suggest that you use these resources as a foundation set of concepts and actions where you and your peers/teams can apply work-place specific versions of the material.
The full version is a large document. The members who are likely to benefit most from reading this comprehensive information are managers and/or educators/supervisors. The full version also touches on areas of clinical governance around clinical notes. Please contact email@example.com for further information