Physiotherapy notes in private practice (UK): HCPC and CSP standards, with an audit checklist

A physiotherapy note is the written account of each contact with a patient: what they told you, what you examined, what you decided, what you did, what advice you gave and what happens next. In private practice you write it, you may own it, and you answer for it if a complaint or claim arrives.

This guide covers what the HCPC and the CSP actually say, what a complete note contains, how to handle timing, corrections, abbreviations, electronic systems and retention, and then gives you a yes/no audit checklist, a template and a short fictional example.

What the HCPC requires: standard 10

The HCPC Standards of conduct, performance and ethics apply to every registered physiotherapist. The current version has been effective since 1 September 2024. Standard 10 is called "Keep records of your work". It has three parts.

• 10.1 "You must keep full, clear and accurate records for everyone you care for, treat or provide other services to."
• 10.2 "You must complete all records promptly and as soon as possible after providing care, treatment or other services."
• 10.3 "You must keep records secure by protecting them from loss, damage or inappropriate access."

Two other standards matter for your notes. Standard 1.4 says you must make sure you have valid consent, "which is voluntary and informed", before you provide care or treatment. Standard 2.3 says you must give service users the information they want or need, in a way they can understand. Your note is where you show both happened.

The HCPC sets the principle. It does not give a list of headings. For detail, physiotherapists turn to the CSP.

What the CSP adds

The Chartered Society of Physiotherapy publishes record keeping guidance, last reviewed on 19 August 2025. Its test for a good note is simple. A good record "will enable an independent reader to understand what conversations took place with a patient", plus "the extent of any examination performed, what treatment was provided and what clinical reasoning decisions were made".

The CSP also points to section 6 of its Quality Assurance Standards for the detailed criteria. That document dates from 2012 (with a 2017 review date) and still refers to the Data Protection Act 1998, so read its data protection parts with current law in mind. Its record keeping criteria remain a useful audit base. Section 6.1.1 says records should, among other things:

• be started at the first contact;
• be written immediately after contact, or before the end of that working day;
• show the date and time of the treatment or advice, and the date and time the entry was made;
• be legible, factual, consistent and accurate;
• be attributable to the person who wrote them;
• show the planned care, decisions, care delivered and information shared;
• identify problems that arose and the action taken;
• show actions agreed with the service user, including consent to treatment or to disclose information.

What a physiotherapy note must contain

Put the HCPC and CSP texts together and a complete note covers seven areas. For a session-by-session view with a downloadable form, see our guide to physiotherapy session notes.

1. Consent

The CSP Quality Assurance Standards (5.1) ask you to obtain and document informed consent before any advice, assessment or treatment. Write what you explained, what the patient agreed to, and any part they declined. If you get written consent, a copy goes in the notes (5.2).

2. Subjective assessment

Record the presenting problem in the patient's words, history, relevant medical history, medication, red flag screening questions and their answers, and the patient's goals.

3. Objective assessment

Record what you examined and what you found. The CSP test asks for "the extent of any examination performed". So note what you did not test as well, if it matters.

4. Clinical reasoning

This is the part most often missing. Write your working impression and why you reached it. Name the findings that support it. If you ruled something out, say how.

5. Treatment given

Record the techniques, dose, position, sets and repetitions, and the patient's response.

6. Advice and information given

Note the exercises prescribed, the self-management advice, and any leaflet or link you handed over. This shows you met HCPC standard 2.3.

7. Outcome measures and plan

The CSP Quality Assurance Standards expect outcome measures to be identified and used at assessment where possible (8.3.5) and the result of each measurement to be recorded (9.4.2). Write the score, the plan, the next appointment and the criteria for discharge or onward referral.

Timing: "promptly" and "end of the working day"

HCPC standard 10.2 uses the words "promptly and as soon as possible". The CSP is more precise. It says notes should be written "immediately after the contact with the service user or before the end of that working day". The CSP accepts this may not always be practical, for example in community work, and says local policies should cover those cases. If you write a note late, record the time you wrote it as well as the time of the session. That is criterion 6.1.1 (c) and (d).

Corrections and amendments

Never delete or overwrite. The CSP says "amendments should be dated, timed and signed and the original entry still clearly visible". On paper, strike through with a single line so the original stays readable. In software, use the amendment function, not a fresh edit of the text.

Abbreviations

The CSP says members "should only use short forms if there is an agreed list developed locally". If you transfer notes, the list must go with them. A sole practitioner can write a one-page glossary and keep it with the files.

Electronic notes

The CSP says electronic systems should show who made each entry, show revisions or amendments, and lock the notes. It gives password protection for static records and encryption when sharing sensitive information as examples of keeping records secure. The CSP does not recommend specific providers. Before you choose software, ask the provider for its data processing agreement and check where the data is held.

The CSP also says that a self-employed sole practitioner owns the notes and must register with the Information Commissioner. If you work for a practice, the employer or contracting practice normally owns them.

How long to keep physiotherapy notes

The CSP guidance gives these periods, presented as NHS minimums that vary across the UK nations:

• Adults: "Eight years from the date of last treatment for adult records."
• Children: "Eight years after their 18 birthday or until 25 years of age for children."

The CSP adds that under GDPR you should keep data only as long as needed for its original purpose. Write your chosen period in a retention policy and tell patients. For a wider look at retention across therapy professions, see how long to keep counselling notes in the UK.

Patients can ask for a copy of their notes. The CSP says requests must be answered within one month, usually free of charge, and that requesters get copies, never originals. Our guide to subject access requests covers the process.

Audit checklist for physiotherapy notes

The CSP Quality Assurance Standards (6.4.2) expect record keeping audits to be planned and carried out annually. A sole practitioner can do this alone. Pick 10 sets of notes at random and answer yes or no to each item. Every "no" becomes an action.

Consent and identification

• Are paper notes in permanent ink, signed with the name printed, and paginated with the date? (CSP guidance)
• Is informed consent to assessment and treatment documented before treatment began? (HCPC 1.4; CSP QA 5.1)
• Is consent to share information documented where information was shared? (CSP QA 6.1.1 i)

Content

• Was the record started at the first contact? (CSP QA 6.1.1 a)
• Can an independent reader see what was discussed? (CSP guidance)
• Is the extent of the examination clear? (CSP guidance)
• Is the clinical reasoning written, not just the findings? (CSP guidance)
• Is the treatment described well enough to repeat it? (CSP QA 6.1.1 g)
• Is the advice and information given recorded? (HCPC 2.3; CSP QA 6.1.1 g)
• Are problems that arose and the action taken recorded? (CSP QA 6.1.1 h)
• Is an outcome measure chosen at assessment and each result recorded? (CSP QA 8.3.5 and 9.4.2)
• Is there a plan with a next step? (CSP QA 6.1.1 g)

Timing and authorship

• Was each entry made immediately after the contact or before the end of that working day? (CSP QA 6.1.1 b; HCPC 10.2)
• Are the date and time of the session shown? (CSP QA 6.1.1 c)
• Are the date and time of the entry shown? (CSP QA 6.1.1 d)
• Can each entry be attributed to its author, with name printed or a system log? (CSP QA 6.1.1 f)

Form

• Is the note legible, factual, consistent and accurate? (CSP QA 6.1.1 e; HCPC 10.1)
• Are amendments dated, timed and signed, with the original still visible? (CSP guidance)
• Are all abbreviations on your agreed list? (CSP guidance; CSP QA 6.2.4 c)

Security and retention

• Are notes protected from loss, damage or inappropriate access? (HCPC 10.3)
• Does your electronic system show authorship and revisions, and lock notes? (CSP guidance)
• Do you have a written retention policy with the CSP periods as a reference? (CSP guidance; CSP QA 6.2.1)
• Do patients know they can access their notes? (CSP QA 6.2.4 b)
• Are you registered with the ICO if you are a sole practitioner? (CSP guidance)

The CSP QA standards (6.4.3 and 6.4.4) expect audit results to be acted on.

Template: initial assessment note

• Header: patient name, date of birth, date and time of session, date and time of entry, clinician name.
• Consent: what was explained, what was agreed, anything declined.
• Subjective: presenting complaint, history, medical history, medication, red flag questions and answers, patient goals.
• Objective: observation, range of movement, strength, neurological tests, special tests, what was not tested.
• Outcome measure: tool used and baseline score.
• Clinical reasoning: working impression and the findings behind it.
• Treatment: what was done, dose, response.
• Advice: exercises, self-management, information given.
• Plan: next appointment, goals, review point, referral criteria.
• Signature: name and role, or system authorship.

Fictional example: low back pain initial assessment

This example is invented for illustration. It does not describe a real patient and is not clinical guidance.

• Header: Patient "J.S.", seen 14:00, note written 14:50 the same day. Clinician A. Physio.
• Consent: Explained assessment and possible treatment options. Patient agreed to assessment, manual therapy and exercise. Declined acupuncture.
• Subjective: Low back pain for 3 weeks after lifting a box. Worse on sitting over 30 minutes. No leg pain. Red flag questions asked: no bladder or bowel change, no saddle numbness, no night sweats, no weight loss. Goal: sit through a working day.
• Objective: Lumbar flexion limited by pain. Neurological screen of lower limbs normal. Hip range full. Thoracic spine not assessed.
• Outcome measure: Pain 6 out of 10 on a numeric rating scale. Function questionnaire completed, score filed.
• Clinical reasoning: Presentation consistent with non-specific low back pain. No neurological signs and no red flags reported, so no onward referral at this stage.
• Treatment: Lumbar mobilisations in prone, 3 sets. Pain on flexion eased after treatment.
• Advice: Stay active. Two home exercises shown and practised, handout given. Told to seek urgent help if bladder or bowel symptoms appear.
• Plan: Review in 1 week. Repeat pain score and questionnaire. Assess thoracic spine.

How Delta fits into your note writing

Delta is an AI assistant for mental health and allied health practitioners, including physiotherapists. During the session, Delta transcribes what is said, then prepares a session report that you review. You can also use dictation after the session, for example to add your objective findings, or type written notes.

The report is added to the client's file, so the whole follow-up and its progress are in one place. Delta also drafts assessment reports and letters. You review, correct and validate every document. The note stays yours, and the HCPC and CSP standards above still apply to what you sign.

On security, data is hosted in France with a host certified for health data (HDS, the French health data hosting certification). AI processing, transcription included, runs on servers located in France. The client's name and identifying details are pseudonymised before AI processing. No audio file is kept, data is never used to train models, and data is encrypted in transit and at rest. You should still ask any provider, Delta included, for its data processing agreement. More on the security page, on Delta for physiotherapists, and in our article on AI in physiotherapy.

Sources

• HCPC, Standards of conduct, performance and ethics (effective 1 September 2024): https://www.hcpc-uk.org/standards/standards-of-conduct-performance-and-ethics/
• CSP, Record keeping guidance (last reviewed 19 August 2025): https://www.csp.org.uk/publications/record-keeping-guidance
• CSP, Quality Assurance Standards for physiotherapy service delivery (2012): https://www.csp.org.uk/system/files/csp_quality_assurance_standards.pdf