Towhomdo cosenotesbelong? - leon Duckworth& Ian Townsend In hispresentationto the Brighton Spring Chair of the PetterVilcsueen, Conference, EuropeanCouncilfor Classical Horneopathy (ECCH),was able to cite exactlythe number of consultations,ad hoc contacts,and phonecalk with one client ouerthe period of treatment- This raisesthe interestingquestion:exactlyhow much do we needto recordin Patient notes?
Scope of notes At college,we are taught to record a case with homeopathic accuracy.We are perhaps not given such detailed advice on how complete the notes need to be to satisff other criteria. In our collectivemove towards professionalisation,we are increasinglycoming under public examination.Where members'noteshauecomeunder such scrutiny (seelegal casep2) they have attractedfavourablecomment. In order to maintain high standardsof patient care in the tight of good practice and recent legislation,our Code revisionsmay eventually Proposethe additions listed
8.1.3 Dates and details of all treatments or therapies given; homeo-
client can seek accessto notes, they do
pathic or otherwise.
not have legal right of ownership.Where you decide to give clients their notes (as
8.1.4 Details of medication being taken by the patient and the name
where they are transferring to another
and profession of the prescriber. 8.2Where possible any diagnosis which a patient has received from any other competent medical authority should be ascertained. 8.3 Decisions that the homeoPath rnakes in the rnanagernent of a patients case,such a refenal to other homeopatlu or health care prafiitioners, disclosure of information or requcst for medical testsand examinations, should be recorded at the time in the patient's notes. 8.4 Advice gwen to the Patient in a clinical or telephone consultation important for improuing the known condition. To maintain a complete record, every individual contact (consultation, letter,
in cases where the client insists on it, or practitioner), the Society recommends you provide a copy and retain the original. Then, should you ever be required to justry a particular treatment or course of action, you have the reference materials to hand.
Who has access? The 1996 Code carries the entry: S.3...Accessshouldbe resuicted to you, your assistants and agents, unless the patient otherwise gives consent. 8.4 A patient may askyou for a record of their consultations and prescriptions, and you should send all the basic and essential information from that patient's case notes as quickly as
phone call, chance meeting) needs to be logged in our notes, which should be
possible. A request from a
belowin italics:
clear, legible, and contain all the relevant information relating to the progress of
be sent to another homeoPath or other practitioner should also
8.1 Full recordsof all treatments of patients should be kePt, including the following details:
the case (i.e. whether the patient has improved, maintained or deteriorated in
be dealt with promptly.
their condition since theywere last seen). This has proved to be vital in ensuring continuity of patient care in locum work
In the light of recent legislation, it is doubtful whether this now goes far
8.1.1 Name,address,telePhone ngmber and date of birth. 8.1.2 Essentialdetailsof medical history; togetherwith denils such as peakflow recordings,blood pressure readings,other medical data such as weight loss,unusualbleeding or other information ProuidedbYthe patient, and including a record of syrnptomsdiuulgedbY the Patient a seriousphysicalor which suggest mental disordermay be Present. i.e. if we carry out orthodox procedures, we need to record their results,and we need to be ableto demonstrateour awarenessif patient symptomatolory suggestspotential seriouspathology, referring to a suitable health practitioner as necessary(see8.3 below)
2000 lune Newsletter
and is particularly important where the homeopath recognises the possibility of legal proceedings for, e.g., child abuse, medical neglect, or malPractice.
patient that their case notes to
enough, since there is a global move towards increased freedom of access to personal information. Providing patients with a short record of their treatment, and a brief list of remedies prescribed is no longer tenable or acceptable.
Who owns the notes? In taking thorough case histories with our clients, we build up impressively detailed and intifnate records of their lives. It is hardly surprising, then, that in the unfortunate event of the homeopath-client relationship breaking down, some clients insist that such histories are theirproperty, and demand the return of any and all notes their practitioner has made. Do they have a right to do so? The legal position is clear. The practitioner recording the case history ovurs it. And, whilst a
lnformed consert z challenges Clients sufferingsevereaggravationsor long-term illnessfollowing homeopathic treatment may saythat if they had been informed of this possibility they would never have giventheir consentto receiving our therapy. The conceptof "informed consent" occurs throughout health care law and representsthe legaland ethical elpression of the human right to have one's
autonomy and self-determination respected(McHale& Fox,1997). In order to give fully informed consent the client must have information about the benefits and risks of any proposed courseof treatment. The NHS Patient's Charter containsthe right of the patient, "To be glven a clear explanation of any treatment proposed, including any risks and alternativesbefore deciding whether or not to agreeto the treatment.r' What doesthis mean for us as homeopaths?We need to inform our clients about significant risks of substantial harm which could occur if treatment were to proceed. If we have not explainedsuch risks and harm were to occur,the client could claim that had s/he known of the possibility of this risk s/he would not have agreedto undergo the treatment. The amount of information given to a client is measuredunder what is known as the'reasonablepractitioner' test. In
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other words, has the homeoPath orplained what s/he intends to do, and included referenceto any possible complications, in a way that any careful and responsiblehomeopath in similar circumstanceswould do? This raisesthe question of consent forms for clients and handouts or explanations outlining what may happen after a remedyhas been taken including the mention of possibleaggravations. Failure to provide sufficient relevant information could leaveus vulnerable to action for negligence.
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Disclosingremedynames One outcome of this emPhasison increasedaccessis a challengeto the conrmon practice of withholding remedy identity.It could be successfullyargued that, in order to obtain informed consent,the client has a right to the identity of the remedy.
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Security and storage 8.5 Patientsrecordsmust be kept secure and confidential at all times. 'Confidential' means,generally,that information in patient notes should not be disclosedto any other party without the orpresswritten permission of the client.The only clear exceptionto this is that we havea statutory duty to disclose where a client revealsknowledgeof terrorist activitY.
There are other exceptionsto the duty to maintain confidentiality: o Whereconsenthasbeen expresslygrvenby the client. o Wheretherapistsworking in a multi-disciplinarysettingneedto sharethe information about the client in order to fulfil their duty towardsthe client and the client hasgiuen her expresswritten permissionfor this to happen. Here,careshould be taken to ensurethat any information sharedis limited to what is relevant to and necessaryfor patient ca,re. o Patientrecordsdo not enjoy legal protection: police can apply to Court for an order for access, which can then insist on disclo' sure. How many of us keep patient recordson computer? And how many of us have registeredwith the Data Protection Agency?If we have not done this, we are breakingthe law rmlnerableto prosecution, and unawareof our own Codeof Ethics:
Duties There are certain matters of which the Societymust inform its members for legal and professionalreasons.If these requirementsare overlooked,you may become involved in difficulties with the generallaw or with other professional or institutional organisations.You are subject to these requirements: 2.L To complywiththelawof the country where you practise. Presentlegislation is very clear on this and has teeth.Failureto register could face one with legal action and a bill of many thousand pounds. Whilst manual (i.e. handwritten) records are not regrsterable,any other computer-based patient data ls. Even a list of client names and addresses,unless maintained onlyfor the purposesof advertising or mailshots, has to be registered.The moment the list is used for mailing treatment (a remedy), we become liable to registration.
Seven years of records All notes should now be kept for a minimrun of sevenyearsfrom the date of the
last consultation, after which they can be destroyed.If the notes are put into storage,we must maintain their security. When we decide to destroyrecordscare must be taken to preservecompleteconfidentiality. All this applies irrespective of whether we have recently seen our clienq and even in the event of a client's demise. Where there is ever a possibility of a client bringing a claim against a practitioner, it is unwise ever to destroy the records - cases can be brought many years after an event or dispute. If there is a possibility of a claim for breach of contract, records need to be kept for at least six years - the period of time within which claims can be brought.
Transfer of notes Our current Code and practice deals reasonablywell with the transfer of notes at the patient's request.However,it is less clear in two important areas: 5.ll On decidingto move or retire from yow practice, you should inform all current patients of your intention to do so and of any iurangements being made for the transfer of the practice to another homeopath. This may be in the form of a local newspaperadvertisement. 5.12 You should make prior ilT.rngements so that your patients are notified in the event of your death, or incapacitating illness. The samegoesfor retirement. Retiring is irrelevant to your duty of care to clients. Unless they authorize transfer to another practitioner, or we iue prepared to let them hold their own notes, we have to retain them securely,as above. The same goesfor selling or transferring the practice to another homeopath on retirement the notes may not be passed on. We cannot passnotes ql to other practitioners - it is a breach of the contract which exists,or is assumedto exist, between practitioner and client. Unlessthe original contract with the client clearly specifiedthis practice, it is unwise automatically to transfer patient notes.What we can do is write to every client, advising them of retirement/sale of practice,askingtheir permission either to transfer their notes to a new practitioner or offering them the opportunity to collect them. Permissionhas to
JuneNewsletter2000
be sought and actiuely giuen - we cannot write "if I do not hear from you within 2 months I will assume I have permission
for seven years? Whilst we may consider that we have made arrangements by talking to a colleague, or mentioning our plans to a next of kin - have we for-
to transfer your notes to . . ."
malised this in a waywhich protects the security and confidentiality of our clients and also ensures continuity of care? Whilst the law is unclear here, good practice might suggest seeking clients'
Long term illnessor death Talking to colleagues, we've found that the possibility of the homeopath's chronic and debilitating illness, or death, to be an €uea of the existing code which has
informed consent to actions such as transfer or return of notes: otherwise
largely been ignored.
secure and confidential storage applies.
Contemplating our own mortality seems a challenging way of caring for our patients. And yet - what haPPens to
As additional issues around the form, storage and access to client case notes emerge, we will bring them to your
client care if we are suddenly injured in a car crash, develop an critically impairing illness, or suddenly die?What then hap-
attention.
pens to the requirement to keep notes
Iean Duckworth and lanTbwnsend are
continuedfrom page19
this period. We now plan to review the whole of the registration process and to make recom-
attending a supervision course and participating in workshopsin the use of NOS and CoreCriteria. Following a comprehensivefeedbackprocessinvolving the various groups involved in the project and culminating in.the group evaluation day in fuly 1999,various modifications and additions were introduced to the project this year. Sincethe RPPwas introduced as an option, 130peoplehavechosenthis method to register,comparedwith 60 who chosethe original method during
mendations to the Board with our findings so that clear decisions can be made for the future. We will be listening to the experiences of assessorswho have worked with both methods of registration, of the LILMs who have now registered, of the Colleges who have administered the original method of registration, and of the wider membership. Please tell us what your views and e:rpe-
References Data Protection RegistrarInformation Line - 01625545745 Dimond B, (1998)TheLegalAspec*of Complementary TherapyPractice, London, Churchill Livingstone. McHale L (1997)Health C.areLaw, London, Sweetand Ma:rwell.
[email protected] before the end of lune. Whateverthe outcome of the reviewit is our intention to maintain the original method as an option at least until December2001,so that those candidates who have alreadybegun to write up their caseswill be able to complete the registration processusing this method. A report of the evaluationwill appear in the SeptemberNewslctter together with any decisionsmade by the Board.
riences are by writing to Awil Baker, 37 Albert Road, London N4 3RP or e-mail
@ (
membersthe ProfessionalConduct SteeringGroupinvoluedin reuisingthe 1996Codeof Ethics,and alsojoint hurse Leaderson the B.Sc.(Hons)Homeopathic Medicinecourse,Universityof Cnntral Lancashire.Jeangained her Law degreein 1991,and has taught the subjectat HE leuelsincethen.
horneopathy
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2000 lune Newsletter
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