Hi Jennahunni
I also found that while it was discussed on mycollege course, and the importance of consultations sheets, signed by client and therapist was made clear, you are right that it is not necessarily made clear how this works in real life! I was asking myself similar questions after qualifying, and now have a system which works for me.
What I do is, complete a full consultation at the first appointment, which is signed and dated, and then have boxes on the sheet which can be signed and dated at any further appointments to confirm that there are no changes. So at a second appointment, I will ask if there have been any changes to health and welbeing since the last appointment. Then the client and me will sign and date the form again to confirm that there are no changes to health, medication, etc. If there are changes these can then be noted and initialled. What I also keep is an A5 index card where I can keep a note of the date, treatment, products used, if any, and any other information relevent to that treatment. This is handy if they are coming regulalry, and especially if having different types of treatment. For reflexology, I do always make notes on a sheet with a footmap on, and complete a new one each appointment marking any imbalance, marks, reactions by the client, etc. and attach these to the consultaion sheet. Also, I will quickly run through my findings with the client, especiallt at a first appointment, or subqequent ones where there have been changes to previous findings, otherwise fairly brief discussion.
You may be able to simplify this, but you should always check for any changes in the client at every appointment and have a clear record that this was covered at each appointment.
Good luck. I'm sure you'll find a system that works, and as time goes on you will change and improve your system.
Hope this helps