Today, litigation involving personal trainers is more common than ever before. Personal trainers must be more cautious and take necessary steps to minimize potential legal risks associated with lawsuits involving claims against professional negligence. Most legal matters taken against personal trainers are very complex and often dependent on whether there is proof to substantiate a particular claim. Written proof is extremely useful when disputing alleged complaints, thus it is very important for personal trainers to maintain detailed records at all times with all clients. How well a personal trainer maintains client records could both corroborate evidence and help their defense or it could hinder their case. There are certain documents and information that is more important than others, however it is the complete picture that will ensure the legal protection a personal trainer needs. Knowing what forms and documentation to maintain is often the question that personal trainers ask. The following are documents that are considered critical and should be maintained on all clients by personal trainers. It is also recommended that you obtain legal review of the documents that you use and the manner in which you are using them.
The informed consent for exercise testing and program participation is one of the most critical documents. It is essential to receive a person’s consent before placing them through any procedure. Without such consent, a person who claims an offensive touching can be characterized as criminal or civil battery. In civil court, compensation can be awarded to the plaintiff. However, if the client consented to the touching or procedure then it can negate the claim. Many issues arise when there is a lack of informed consent or if the consent was obtained through fraudulent actions or misrepresentations. To prevent from potential action against personal trainers, it is necessary to ensure proper evidence of the consent process. That means that you should be able to produce a valid informed consent on file from each client. The following are elements, which are required for a valid informed consent:
- The person must be over 18 and otherwise legally capable of giving consent.
- Fully understand all the risks and benefits associated with the procedure or program that they are going to participate in.
- Giving consent voluntarily and not under mistake of fact or duress.
In practice, an informed consent should be in written form and should be preceded by a verbal disclosure to the client regarding all the risks and benefits. The client should always have an opportunity to ask questions and have those questions answered to their satisfaction. Should there be any information that might be relevant to the informed consent process, it must be documented in the client’s file in case there are any questions raised later. It is also recommended to give a copy of the informed consent with all the appropriate signatures and any notes that were made during the process. Keep in mind that should any changes be made after the original form is signed, these changes should be noted (dated and time stamped) and included as a supplemental notation.
There is always a risk to recommending activity or exercise testing without proper physician’s clearance, especially for those clients considered high risk. There are guidelines established by the American College of Sports Medicine (ACSM) for the recommendations of a physician’s clearance for exercise testing and participation. According to ACSM, personal trainers should receive medical clearance on the following clients before beginning:
- Any individual participating in moderate activity who is stratified as high risk
- Any individual participating in vigorous exercise who is stratified as moderate risk or high risk
(NOTE: Moderate risk is considered older individuals (men > 45 and women > 55) or those with two or more risk factors. High risk is considered any individual with one or more signs/symptoms of cardiovascular and pulmonary disease or with known cardiovascular, pulmonary or metabolic disease).
Keep in mind, even if a medical clearance is obtained, a physician should professionally analyze future concerns. Having one clearance at the start of the training might not be the only one that is necessary.
Documentation and Recordkeeping:
The need for detailed documentation of all actions, observations, program prescriptions and discussions cannot be understated. It is extremely important for a personal trainer to maintain written documentation on all clients at all times. The following is a list of important information that should be maintained on all clients. It should be noted that this is not an exhaustive list.
- Informed consent for exercise tests and program participation
- Results from any exercise tests
- Personal trainer’s conclusions from the tests indicating the fitness level of the participant. The client’s restrictions or capabilities that are based on the exercise tests or physician’s recommendations.
- Exercise prescriptions and related recommendations for physical training
- Interview notes from any conversation held with the client regarding the exercise testing or program prescription.
- Any special instructions given to the client relative to the program
- Warnings conveyed to the client as to the potential signs and symptoms of exercise, particular limitations or exercise instructions
- Any observations made by the personal trainer regarding any unusual problems with the performance of the exercise, which might suggest concerns for tolerance to the program. Any modifications that were made because of these observations and how the client responded to them.
- Any documentation regarding the techniques, use of the equipment, compliance programs or concerns and progress charts documenting the progression made by the client.
- Any time you need to reinstruct the client on any or all of the above
- Any information regarding injuries and emergency first aid that has been administered as a result of an injury.
Documentation is one of the best defense tools for a personal trainer. All personal trainers should make sure that their client files are kept current. The information should be kept neat and orderly so that it can be easily read and understood. It is recommended that a lawyer review the documents to ensure that they meet the standards of the state in which the trainer works. When it comes to potential litigation, documentation can help minimize the risks that personal trainers face today. Therefore, the extra effort it takes to complete the paper work for each client is certainly worth the effort.