Insurance for fitness professionals, gyms, and fitness centres

Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for fitness professionals to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many fitness professionals would benefit from learning more about good record keeping.

Record keeping and insurance claims

Why is an insurer so concerned about record keeping? It’s because client records can greatly impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to poor or unexpected outcomes following training sessions, such as an injury, leading to the client complaining and possibly seeking some form of compensation.

All fitness professionals would want to avoid client injuries as the wellbeing of their clients is paramount.  They would also want to avoid complaints, which can lead to insurance claims, as these can be very challenging and confronting experiences. Therefore, understanding how to improve the standard of client records really should be a core focus.

Why keep detailed client records?

Continuity of service

It’s not uncommon to hear professionals say they can remember the details of each of their clients and any interactions with them. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of their sessions or consultations, and this has led to a poor outcome for the client.  It’s therefore imperative to record details about all training sessions, with specific information about what exercises were performed and how the client responded to them.  It’s also important to refer to this information within the client’s record when planning future sessions. 

Professional expectation

All professionals need to be aware of the various expectations placed on them, which are there to assist them to carry out their work appropriately.  And it’s a common expectation that professionals keep detailed records of client interaction; this is no different for fitness professionals.

In the AUSactive Code of Ethical Conduct, it’s stated that AUSactive professionals are required to ‘Maintain complete records of services provided to clients, including records of pre-exercise screening, client progress, and referrals’. 

Defence of a complaint

If there’s any allegation of wrongdoing made against a fitness professional, their records are going to be incredibly important. Those records provide evidence of what took place and why during sessions with clients. Without this, the professional will be relying on their memory as a defence. Information recorded at the time of the session is going to hold greater weight as a reliable defence than a professional’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for services provided and can conduct audits to be sure professionals are billing appropriately. It’s not uncommon for a professional to receive a request from a funding provider to produce records to justify their billing practices.  If the reasons behind the service, and therefore the billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many professionals ask when it comes to record keeping is ‘how much detail do I need to record?’. Exactly what to include will vary according to the specifics of each fitness session as well as the individual client.  However, generally records should include, but aren’t limited to:

• Client identifying details and contact information
• Pre exercise screening information
• Date of the session
• Relevant pre exercise discussion – for example, how the client is feeling and what their expectations are 
• Details of all exercises including
  • Warm up and cool down exercises
  • Core program exercises
  • Number of reps
  • Number of sets
  • Weights or resistance level
  • Modifications made to the program
• Client’s response to exercises – did they struggle, feel pain or discomfort, are they ready to advance in the program etc
• Any instructions given to the client for exercise outside of the session times
• Referrals to health professionals or anyone else
  

When a professional is unsure if they’ve included enough detail, they should ask them self whether or not another professional could read the record and understand the full picture of what took place, without the need to fill in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about the client can be included, however this must be professional and only done when relevant to the exercise instruction being provided. This may occur in situations where the client isn’t able to follow instructions or perform exercises correctly and this could lead to injuries or a lack of progression.  However, it’s important to remember that client records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a fitness professional would use when speaking to the client during an exercise session.

Download pdf article here.