Client record keeping in Ireland: A guide for health and wellbeing practitioners

Your client notes are more than admin; they can be an important line of defence if something goes wrong or if a client makes a complaint or claim against you. Clear, complete and accessible records help you to support safe treatments, meet best practice guidelines and insurance requirements, and protect your livelihood as a health or wellbeing practitioner in Ireland.

Why do my records matter?

Because they help to protect you and your clients. If there’s ever a complaint or claim, your treatment notes can form an important part of the evidence. They show that the treatment took place, how you assessed suitability, your clinical reasoning, what was discussed, and why you made each decision. Good record keeping also supports continuity of care, backs up the pre treatment information you gave, and reinforces any post treatment advice you provided.

This article is written for health and wellbeing practitioners working in the Republic of Ireland. Laws, regulatory expectations and professional guidance can differ in other countries, so always check the rules that apply where you are.

What to record

The information you record will depend on the sorts of therapies or activities you offer but your Balens policy includes a record keeping condition that sets out the minimum information you’re required to keep in the event of a claim.

As a practical guide you should look to record the following information:

• Pre‑treatment or pre‑session consultation: Presenting issue, relevant medical conditions, medications, allergies and contraindications.
• Suitability and consent: Your assessment of whether the treatment or activity is suitable, whether informed consent has been taken, and how that consent was obtained (for example, written form, online form, or verbal consent recorded in the notes).
• Treatment plan and any adjustments: What activities or techniques you plan to use and any modifications or adjustments you make to ensure suitability. Include your rationale for key decisions, along with any pre‑ or post‑session information or advice you provide.
• Session details: Date and appointment times, client responses, outcomes and any adverse events or concerns raised.
• Testing and safeguarding: Evidence of patch testing where appropriate as well as any safeguarding concerned you’ve noted and acted on.

The full record keeping condition can be found in your Balens policy wording.

Your records should be kept in a durable medium, and you need to ensure access in the event of a claim.

How long to keep records

Your Balens policy includes a condition that specifies you must keep your records as follows to comply with your policy:

• For treatment with adults: A minimum of 6 years
• For treatment with minors: 6 years after they turn 18.
• For vulnerable adults: Consider retaining records beyond 6 years, as limitation periods may be extended by the courts in Ireland.

Under data protection law, including GDPR and the Data Protection Act 2018, records should generally be kept for “no longer than necessary”, although the exact time is not specified and depends on your circumstances. Records may be kept where this is necessary for the establishment, exercise or defence of legal claims.

If you are unsure, take extra care. Slow down, explain simply, check understanding. Where capacity is a concern, consider any guidance from your Irish professional body and, if needed, seek advice on how the Assisted Decision‑Making (Capacity) Act 2015-2022 may apply in your situation. Your notes should reflect any capacity concerns you identified and the steps you took in response.

Who owns the notes? Who can see them?

In many therapeutic settings, client records are held by the practitioner or clinic, even if you move practice, refer the client on, or supervise a student under your insurance (in which case, the records are usually yours to maintain).

Where you are working in a clinic or as part of a multi‑disciplinary team in Ireland, it is important you either keep individual client records yourself or can access them in the event of a claim.

Clients also have rights to access their personal data under Irish data protection law and guidance from the Data Protection Commission.

If you move, sell, or stop practising

You must ensure you have ongoing access to your treatment records for insurance and professional purposes. This may also be important in the event of illness or incapacity, for example by setting out any arrangements in a will or through a power of attorney so that your records can be managed appropriately and, where necessary, accessed if a claim arises.

Record keeping in practice

Scenario one:

A client attends a session with you at your therapy clinic. As part of the consultation, you ask about allergies, the client says they don’t have any and you record this in their treatment record. Later, the client experiences an allergic reaction to a product you either used on them or recommended.

In this scenario, the consultation information is important evidence. It shows:

• The allergy question was asked clearly as part of standard practice.
• The client did not disclose any allergies at the time.
• The recommendation was made based on the information your client shared with you.

These records help you to demonstrate you exercised reasonable care, followed your usual procedures, and weren’t negligent in the circumstances.

Scenario two:

During a group fitness class in a community centre, a participant alleges you pressured them to continue despite reporting discomfort, leading to a strained muscle. They later claim you ignored their concerns.

In this scenario, the records form an important part of the evidence. They show:

• A pre‑exercise screening form completed and stored, with no contraindications disclosed.
• A brief class plan and risk assessment on file.
• An attendee list with date, time and instructor details.
• Notes of when the participant reported discomfort and what modifications or alternatives were suggested.
• Aftercare recorded, including any advice to rest, seek a medical review or follow up with their GP.

Clear, timely notes, kept in a durable format and retained in line with your Balens policy, support good care and help protect your cover if issues arise.

Disclaimer: The information in this article is provided as general guidance only and does not constitute legal, regulatory, clinical or professional advice. It may not address all of the requirements or circumstances that apply to your particular situation. If you need specific advice relating to your own circumstances, please contact us in the first instance if you are a Balens client.

All case studies are illustrative only and do not describe real clients or situations.