Documentation, Interprofessional Collaboration, and Professional Safety
Documentation
Notes should be contemporaneous, objective, and defensible: date, session, pre- and post-exercise vitals, exercises with sets, reps, and load, RPE, symptoms, client response, education provided, and plan. SOAP (subjective, objective, assessment, plan) or DAP formats both work if applied consistently. Record measurable facts ("completed 18 of 20 prescribed minutes") rather than judgments ("unmotivated"). Document physician-imposed parameters - heart rate ceilings, weight-bearing restrictions, MET limits - and any clearance letters received.
Confidentiality and scope
Protected health information is shared only with written authorization or as required in an emergency. The specialist's scope is exercise, education, and referral - not diagnosis, prescription, or individualized diets. Know local rules for records retention and release.
Interprofessional collaboration
Referral letters should state the question, the observed data, and what was already tried. Close the loop: note whether the physician replied and what changed. Respect role boundaries, and be explicit in team meetings about who owns which decision.
Safety
Maintain a written emergency action plan covering recognition, calling emergency services, CPR and AED use, and post-event documentation; rehearse it. Check equipment, keep pathways clear, and follow bloodborne pathogen precautions. Watch for dual relationships and boundary drift with long-term clients.
Traps
Charting opinions as facts; backdating or editing a note without an addendum; releasing records casually; exceeding scope by adjusting medication or issuing a diagnosis; and keeping an emergency plan that exists only on paper.
Rule of thumb
If it is not documented, it did not happen - write what you saw, what you did, how the client responded, and what you told them.
Worked example: "Physician clearance dated 3/2 limits HR to 120 bpm; session peak 112 bpm, RPE 12, no symptoms reported."