Every physiotherapist writes notes. Far fewer have ever had one read back to them by somebody who was not in the room — a regulator, a solicitor, a colleague covering annual leave, an insurer deciding whether to fund another six sessions.
That is the actual test. Not whether the note jogs your memory, but whether it stands up when you are not there to explain it.
A note has four readers, and only one of them is you
It helps to write with all four in mind, because they want different things.
You, in eighteen months. The patient comes back with the same shoulder. What did you find, what did you try, what worked and what you abandoned. Most notes serve this reader adequately.
A colleague covering for you. They have ten minutes before the patient walks in. Can they pick up the course of treatment without ringing you on holiday? This is where notes written in personal shorthand fall apart.
A funder. An insurer, a health fund, a compensation scheme, a case manager. They are looking for a stated problem, a plan, and evidence that something changed. Vague notes get claims declined, and the patient wears it.
A regulator or a court. Rare, and the one everybody thinks about at three in the morning. Here the question is almost never "was the treatment right". It is "what did you record at the time, and can you show it has not been altered since". A thin note is not proof of poor care, but it removes your ability to demonstrate good care.
What goes in, including the bits people skip
The clinical content is the part you already know: presenting problem and history, objective findings and measurements, what you did, how they responded, the plan. Nobody needs a physiotherapist to be told what a subjective assessment contains.
The parts that go missing are almost always administrative, and they are the parts that matter when a note is scrutinised:
- Consent. That you explained the proposed treatment, the material risks and the alternatives, and that the patient agreed. For anything higher-risk — manipulation, dry needling, anything involving undressing or sensitive regions — record the conversation, not just the word "consented".
- What you told the patient. Home exercises given, load or activity advice, red-flag warnings, when to seek further review. If a patient later says they were never warned, the note is your only account of that conversation.
- Contacts outside the session. Phone calls, emails, texts about their condition, the letter to the GP. These are clinical records too, and they are the ones most often absent.
- Did-not-attends and cancellations. Record them, with the date. A pattern of missed sessions is clinically relevant and it is also the thing you will want on file if a course of treatment is later questioned.
- Who wrote it. Name and role, and the date it was written — which is not always the date of the session.
- Discharge. The status at the end, the outcome, and what you advised. Courses of treatment that simply stop being mentioned look, on paper, like the patient was abandoned.
A practical test. Take a note from three months ago at random. Hand it to a physio who has never met the patient and ask them to run the next session. Whatever they have to ask you is what is missing from your template — not from that one note.
SOAP, and the way it quietly fails
SOAP — subjective, objective, assessment, plan — earns its place. It is fast, it is universally understood, and a colleague can find what they need without reading the whole entry.
The failure is specific and extremely common: the A gets skipped. People write what the patient said, write what they measured, then jump to what they will do next week. The clinical reasoning — why these findings mean this diagnosis, why the plan is changing, what would make you reconsider — never gets written down.
That missing paragraph is exactly what a reviewer is looking for. It is also the paragraph you will want in eighteen months when the same patient returns and you cannot remember why you dropped the manual therapy.
The second failure is copy-forward. Duplicating last week's entry and changing two numbers is efficient and it produces six identical notes that demonstrate nothing. If three sessions genuinely look the same, that is itself a clinical finding worth writing: no change, plan reconsidered, here is why.
Whether you use SOAP, a structured assessment form by specialty, or your own layout matters less than being consistent. An auditor can follow any coherent format. What they cannot follow is a different shape every week.
How long you have to keep records
This is where practitioners get caught out, because the professional regulator and the retention period usually come from two different places.
In Australia, the Physiotherapy Board and AHPRA require you to keep accurate, contemporaneous records — but the number of years comes from state and territory health records legislation, not from the Board. In New South Wales and Victoria the standard figure is seven years from the last occasion of service for an adult, and for a patient who was under 18, until they turn 25. Other states and territories are not identical, so check your own.
In New Zealand, the Health (Retention of Health Information) Regulations set ten years from the last service.
In the United Kingdom, the HCPC standards require you to keep full, clear records; the retention period most private practitioners work to is the NHS Records Management Code of Practice figure of eight years after the last contact for an adult, and for children, until their 25th birthday. Scotland and Northern Ireland have their own codes.
In Canada it is provincial. In Ontario, for example, the College of Physiotherapists requires records to be kept for ten years after the last interaction, or ten years after the patient turns 18.
| Where | Adult records | Patient under 18 |
|---|---|---|
| NSW & Victoria, Australia | 7 years from last service | Until the patient turns 25 |
| New Zealand | 10 years from last service | 10 years from last service |
| England (NHS code, widely followed in private practice) | 8 years after last contact | Until the patient turns 25 |
| Ontario, Canada | 10 years after last interaction | 10 years after the patient turns 18 |
Treat that table as a starting point, not as advice. These rules are amended, they differ by state and province, and your professional indemnity insurer may require longer than the legal minimum — which in practice becomes your real obligation. Confirm the current wording for where you practise, and confirm it with your indemnity provider before you destroy anything.
One more thing that catches people: the clock usually runs from the last contact, not the first. A patient you saw in 2019 and again in 2026 resets the count to 2026.
Amending a note without making it worse
You will get something wrong. Wrong side, wrong date, a measurement transcribed badly, something you genuinely forgot to write. Correcting it is expected and entirely legitimate. Overwriting it is not.
The principle is the same on paper and on screen: the original stays readable, the correction is clearly identified as a correction, and it carries its own date and your name. On paper that is a single line through the error, initialled — never correction fluid, never a fresh page. On a screen it should be an amendment the system records as an amendment.
An entry added days later is fine as long as it says so. "Written 14 March, regarding the session of 9 March" is a legitimate record. The same words dated 9 March are not, and that is the distinction that turns a paperwork slip into a credibility problem.
Records that keep their own history
Physioly stores every session on a timeline, with a change log across patient records, and exports to PDF whenever someone asks for one. Free plan, no card, first 7 days unlimited.
Create a free account → No credit card. The first 7 days have no limits at all.Going digital: what changes and what does not
What does not change: the content. An electronic record has to contain exactly what a paper one did. Software does not lower the bar, and a tidy screen can hide a thin note better than a paper page can.
What does change is everything around the note. Legibility stops being an issue. So does "which folder is it in". Backups happen without you remembering. Access can be restricted per person rather than per filing cabinet. And an electronic system can record who opened a record and who changed what, which paper simply cannot.
What to check before you trust any system with clinical records:
- Can you export everything, in a readable format, without asking permission?
- Are backups automatic, and has anyone ever tested restoring one?
- Is there a change log, and can you see it?
- Who at the vendor can read your patients' records, and under what circumstances?
- If you stop paying, what happens to the data — and how long do you have to get it out?
Where Physioly stands on those, plainly. Records sit on a session timeline with the pain scale charted across the course of treatment, assessment forms are structured by specialty, and any record exports to PDF. There is a change log over patient records and clinical content. Backups run daily.
Two honest limits. First, diary bookings are deliberately excluded from that change log — a single recurring booking creates dozens of rows and would bury everything else — so if you need an audit trail over appointment times specifically, Physioly is not it. Second, Physioly will not destroy records for you at the end of a retention period. There is no rule that deletes a file at seven or eight or ten years. Records stay until you remove them, which means the retention decision remains yours, exactly as it was with a filing cabinet.
Questions we get asked
How long do physiotherapists have to keep patient records?
It depends where you practise, and the period comes from health records legislation rather than from the professional regulator. In NSW and Victoria the usual figure is 7 years from the last occasion of service, and until age 25 for a patient who was under 18. New Zealand sets 10 years. In England, private practitioners commonly follow the NHS code figure of 8 years after last contact. In Ontario the College requires 10 years after the last interaction. Check the current rules for your jurisdiction and your indemnity insurer’s requirement, which may be longer.
Are SOAP notes still required for physiotherapy?
No regulator mandates SOAP specifically. What is required is a full, clear, contemporaneous record. SOAP is a widely understood way of achieving that, and its most common weakness is that the assessment section — the clinical reasoning — gets skipped, which is precisely the part a reviewer looks for.
Can I correct a physiotherapy note after I have written it?
Yes, and it is expected. The original must remain readable, the correction must be identifiable as a correction, and it must carry its own date and your name. On paper, a single struck-through line, initialled. In software, an amendment the system records as an amendment. A late entry is fine provided it states when it was written and which session it refers to.
Does electronic record keeping satisfy AHPRA and HCPC requirements?
Both accept electronic records. What they require is that records are accurate, contemporaneous, legible, secure, attributable to an identified author and retained for the required period. The format is not the point. In practice a well-run electronic system makes several of those easier to demonstrate than paper does, particularly attribution and security.
Does Physioly delete records automatically when the retention period ends?
No. Physioly keeps records until you delete them. There is no automatic destruction at 7, 8 or 10 years, so deciding when a record has passed its retention period, and acting on it, stays with you.