● Be aware of cultural differences that may influence effective communication with clients. Key principles of informed consent include the following: ● Informed consent is always specific to the individual patient, the clinical situation, and the recommended plan of care or recommended treatment or procedure. ● Practitioners provide the information that a “reasonable person” in similar circumstances would want to know when making the treatment decision. Explain why the practitioner believes that recommended treatments or procedures will be more beneficial than alternatives in the context of the patient’s diagnosis. ● Consent for multiple treatments: separate consent is always required for every episode of repeated treatment. When the plan of care for a given diagnosis involves repeated treatments or procedures, practitioners should ensure that patients understand that they are consenting to multiple episodes of treatment. Separate consent is not required for each individual session. ● If a patient’s condition changes, and a change in the care plan is indicated, the practitioner must explain to the patient how the situation has changed, establish new goals of care to address the new situation, recommend a new plan of care, and obtain informed consent for the new plan or for specific treatment or procedure recommended. ● Notification versus consent: informed consent differs from “notification,” which is general information relevant to clients’ participation in health care. Patients must be notified that their records will be used for purposes of routine healthcare operations. Likewise, patients should be notified that their information may be used for quality improvement purposes to enable the organization to fulfill its obligation to monitor the quality of care it delivers and to carry out quality improvement activities for the benefit of all clients (Quizlet, 2016). Informed consent should: ● Inform the patient regarding the recommended treatment or procedure, including: 1. The name, nature, and details of the recommended treatment or procedure. 2. Indications for the recommended course of action. 3. Likelihood of success of the recommended treatment or procedure for this patient.
Clients should fill out a formal intake form on their first visit that includes: 1. Client’s name, address, and telephone or other contact number(s). 4. Insurance/payment methods. 5. Emergency contact information. The client should also sign and date the following statements: 1. Release of medical records. 2. Notice of informed consent, with scope and limitations of practice. 3. Client’s bill of rights. A client’s bill of rights typically includes the following information: ● Name of practitioner. ● Details of practitioner certification and list of credentials. ● Practitioner’s area(s) of expertise, philosophy, and/or approach to massage. ● Fees and service schedule. ● Payment terms. ● Filing procedures for written complaints. ● A right to information statement, asserting the client’s right to the following information: 1. Practitioner’s assessment of the client’s physical condition. 2. Recommended treatment, estimated duration of treatment, and expected results. 3. Copy of client’s health forms/records held by practitioner: ▪ Statement of confidentiality. 2. Reason for visit. 3. Medical history. ▪ Statement of refusal, explaining the client’s right to terminate a course of treatment at any time, and to choose a new practitioner. ▪ Clients’ right to invoke, explaining client’s right to invoke these rights without fear of reprisal. Both the practitioner and client are ensured the “right of refusal.” For a client, this means the right to refuse, modify, or terminate treatment regardless of any prior agreements or statements of consent. For a practitioner, this means the right to refuse to treat any person or condition for just and reasonable cause. These rights safeguard a client’s freedom to choose any practitioner, and a practitioner’s freedom to terminate treatment, if necessary. These rights might come into play in cases of negligence or abuse. For example, practitioners can refuse to work with an abusive or unstable client, and clients can refuse treatment from a practitioner they suspect is practicing under the influence of alcohol, drugs, or any illegal substances. 4. Confidential information is released only in accordance with applicable state and federal laws. 5. Appropriate safeguards are in place to protect the confidentiality of the record, in compliance with applicable state and federal laws, including HIPAA. B. Minimum Documentation Standards: 1. Records must be legible, accurate, current, detailed, and organized to permit effective and confidential patient care and quality review. 2. Each chart entry must be dated. 3. Each chart entry must have author identification, and title with a legible signature and co-signature (if applicable). 4. Two forms of patient identification information must be noted on each printed page, i.e., name and date of birth (DOB). 5. Personal biographical data, DOB, sex, race/ethnicity, mailing/residential address, employer, telephone number(s), emergency contact information, marital status, consent forms, and guardianship information, if applicable, may be recorded.
DOCUMENTATION AND RECORDS MAINTENANCE
Proper documentation and record keeping is a critical aspect of a successful practice and therapists should keep legible and accurate notes. If therapists or other professionals refer to files at some time in the future, for a medical emergency or legal proceeding, the context and details of the notes needs to be clear. Other healthcare personnel will need to know the background, presenting status, actions taken and the results, with some discussion of treatment strategies and expected objectives. Medical massage therapists should adhere to the requirements of their state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA) (HHS, 2016b). The following are general guidelines for preparing and maintaining records: A. Confidentiality and Security Standards: 1. Treated as confidential information. 2. Stored in a centralized secure location accessible only to authorized personnel who are periodically provided training for confidentiality and security of patient information. 3. Retrievable in a timely manner by office staff and practitioners.
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Book Code: MLA1224
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