Posts tagged " Medical History "

WHAT PATIENT RECORDS SHOULD I KEEP AS A THERAPIST?

July 24th, 2019 Posted by Acupuncture, Alternative Medicine, Consent forms, Consultation Forms, GDPR, Holistic Health, Hypnotherapy, Insurance, Medical History Form, Paperless, Uncategorized No Comment yet

As a Therapist. you need to keep a lot of information about your clients and their treatment.

In fact, your insurance against malpractice or negligence claims policy demands it and Insurers can be quite specific. 

I checked the small print from Professional Indemnity Insurance policies for Alternative practitioners. Here are some things I discovered, I hope they help.

YOUR INSURANCE DEPENDS ON YOUR RECORDS

Insurers require you to take consultation records and then retain those records. One policy I checked asked for five years, but most require seven years, after the last treatment given. 

Insurers advise that you keep the records of minors for at least 7 years after the minor reaches 18.

You should record the client’s full name, date of consultation and notes on their lifestyle/medical history. Also, you should record the treatment you gave the client.

Notes should at least include a brief description of the therapy or treatment. 

The therapist must adequately record each and every treatment given to each and every client. 

The record is to include full details of the consultation process, the treatment, the result of the treatment and any aftercare instructions given where appropriate.

Any adverse reaction to the therapy or treatment must be recorded either separately or as part of the notes already used.

RECORDS MUST BE ACCESSIBLE

You will be need to produce your records of the client/event In the event of a claim. This is to protect you in the event of a claim against you.

Where therapists work in a gym, sports or leisure centre, or a shared practice often the Centre keeps these records.  

You must advise the Centre of any unusual events or of any injuries sustained during your class. 

You must ensure that the Centre will give you access to your records. To protect yourself in case a claim is made against you in the future.

You should record the name and brief details of the person. The date of the session and the therapy given, at demonstration sessions or public events.

If you give Yoga, Pilates, Fitness, Exercise, Meditation therapy, record the name and brief details of the person, date of the session and any other relevant facts.

When new clients attend your class, you should talk to them and ensure that there is no reason why they should not attend your class. If in doubt you should ask for their GP’s confirmation that they can safely participate in your class. 

At the start of each class please ask all participants is there any change in their circumstances that might affect their ability to participate in and complete the class safely.

You must produce your records of the client/event. You must adequately record each and every treatment given to each and every client. This protects you in the event of a claim being made against you.

WE CAN HELP

Using iPEGS forms is economical, quick, tidy, neat and professional. No papers to find, no filing to do.

By using the iPEGS Paperless System for your Consultation Forms, Consent Forms, Medical Histories and Treatment Plans, you can be sure that your data is safe. Saved to the cloud there is no risk of a computer breakdown losing all your data. As the data processor we store and encrypt your data in a secure, state of the art, UK data centre.

We are Cyber Essentials Certified giving you peace of mind that our defences will protect against the most common cyber-attacks.

We have achieved the IASME governance standard in relation to GDPR where we have demonstrated wider governance for management of the controls protecting personal data.

If you would like to know more simply email me: steve @ipegs.co.uk or call me directly on: 01244 955350 and we can discuss how iPEGS can help improve your client’s experience.

Acupuncture Consent Forms and Medical History Forms

March 11th, 2019 Posted by Acupuncture, Alternative Medicine, Consent forms, Consultation Forms, Medical History Form, Paperless No Comment yet

Medical History and Consent Forms in Acupuncture

As an Acupuncturist, you carry a huge responsibility for the welfare of your clients, many of whom have been suffering ill health for years. Often you are the last port of call, after mainstream medicine has failed to provide relief from a chronic condition.

Taking a thorough medical history of each new patient is your first step in providing for a patient’s needs, firstly you need to ensure that acupuncture is the appropriate treatment for your client. People often have an unclear idea of what acupuncture can do, after all acupuncture is not a miracle cure for anything, it is a science.

In obtaining their medical history, there is a need to gain a thorough understanding of a patient’s main complaint and general health and lifestyle. This involves asking questions about current symptoms as well as medical history, such things as sleeping patterns, appetite and digestion, emotional wellbeing. Women must be asked about their menstrual cycle and any past pregnancies and childbirth. The use of pharmaceutical products must be considered in detail, side effects are often hard to distinguish from the ailment. Some patients have suffered chronic conditions for years before considering acupuncture and have tried a series of treatments that have failed, so this medical history is a vital tool for achieving a successful outcome.

Getting that history can be a long and exhaustive process, you need to know as much about past treatments as possible and that can take time to remember.

Using an electronic consent form that can be sent in advance to the client, can gain a depth of information that is hard to get in a first consultation. All this information needs to be recorded and considered thoroughly before a treatment plan can be agreed and put into place.

By using iPEGS Remote paperless forms you can send out the questionnaire a week before the first appointment. It is totally secure and can be customised to suit the patient. They can fill in the history and return it using any connected device, be it smart phone, P.C. or tablet.

People are so accustomed to using communications technology these days, filling in a form at home in their own time can be so much less stressful than in a busy surgery, with limited time.

As for the practitioner you are receiving a fuller history in anticipation of your first consultation, even having time to consult with colleagues, if necessary. There can be a due date set for the form to be returned for just that purpose, with reminders embedded in the process. Once the form is sent, it is automatically filed, unlike paper forms there is no possibility of it being mislaid. It is a permanent record of your patient’s history and current condition.

Once you have had the opportunity to study this and meet your patient, you can explain your findings to them and ensure that they understand. Informing them clearly of the nature and purpose of any proposed treatment you gain their consent to treatment. This of course needs to be recorded.

Although consent may in the past have been taken as implied by a patient’s actions in turning up and lying on the treatment couch, explicit consent is now considered essential.

The law states that, consent must be given by a legally competent person, in some cases the next-of-kin. It must be given voluntarily and must be informed.

You must be able to prove you have sought explicit consent and ensure that the patient has understood what you propose to do. This is particularly important where treatment may involve sensitive areas of the body. It may be construed as an assault to examine or even prepare to treat someone without consent.

You cannot delegate the obtaining of consent to a receptionist or unqualified assistant. Informed consent requires that you as the practitioner (or an appropriately qualified colleague) have explained the procedure, been available to answer questions and able to satisfy yourself that the patient understands what they have been told. So it is up to you the practitioner not only to personally supervise treatment but also consent to treatment.

Having proof of consent is of course part of your duty of care not only to your patient but also for your practice.

So an acupuncture consent form must be signed very early on in the treatment process, again this consent form can be digital, secure and paperless. Using the iPEGS paperless forms, consent can be rapidly given, directly on to a tablet or even a mobile phone, even including a photo for confirmation. Instantaneously becoming a matter of record.

By using a iPEGS digital consent form, you can customise the form in real time, making changes without having to wait on printers, receptionists etc, time saved can be used in treating the patient, which after all is the object of the process.

Storing these Forms is also more complex than you might imagine.

You may well know you are legally required to keep patient records for a minimum of seven years. In the case of minors’ records must be kept until the patient reaches the age of twenty-five (seven years after reaching eighteen). Did you know that this applies even when you have referred the patient on, or you have left the practice where you administered the treatment?

There is also a legal requirement to retain original records which applies in the buying and selling of a practice and even with a patient’s consent, you must only pass on copies of the records, not the original notes?

Making copies of thousands of paper records is a mammoth task, digitally using iPEGS it can be done in a fraction of the time. You may not envisage selling the practice, but you will want to retire sometime.

You must also ensure that patients are kept fully informed and offered appropriate choices about their continuing care and the safe-keeping and location of their original records. Knowing that they are secured gives peace of mind to you and your patient. Doing this with thousands of separate paper documents is literally a forest of wasted time and space.

Patient records must be kept secure and confidential at all times. The UK data protection regime is set out in the DPA 2018 which replaces the Data Protection Act 1998, and came into effect on 25 May 2018, along with the GDPR (which also forms part of UK law). The law applies to any ‘processing of personal data’, and will catch most businesses and organisations, whatever their size and the law provides stronger protection for more sensitive information such as health related data.

Wouldn’t it be useful to get fuller more reliable patient histories?

Can you really afford to take risks with your patient’s records?

Can you afford the space and time that paper forms take up?

Wouldn’t it be simpler and more efficient to go digital and paperless, like many of your colleagues in the health sector are now doing?

Would you prefer not to have the worry of a disgruntled patient with a lost consent form?

If your answer is yes to any or all of the above, or if you are not sure, then why not get in touch, and let iPEGS take you through the process of going paperless.

We are all busy, but sometimes we have to invest time to save it, for our patients and our practice.

Just follow the links on this page and you can be up and running digitally in less than the time of an average consult. If you feel that you have questions you need answered that are not covered on the site, why not book in a call at a time that suits you best? You can do this via the link below and let us walk you through how iPEGS can help improve your processes:

https://calendly.com/ipegs/15-minute-phone-call/

For  more information please click here or feel free to drop me an email: steve @ ipegs.co.uk