The keeping of comprehensive clinical records is a fundamental requirement and the best way a Chinese medicine practitioner can demonstrate good care.
Useful tips on what information should be included to ensure your clinical records are compliant include:
- The patient’s presenting condition and health assessment
- Recording pre and existing medical conditions/allergies and family history of any related medical conditions
- Co-morbidities
- Allergies
- Contra-indications
- Concurrent treatment(s)
- Chinese medicine diagnosis
- Treatment rationale
- Treatment principle
- Treatment methods/procedures/acupuncture points used/techniques/herbal prescriptions
- Treatment plan/evaluation/progress
- Anticipated number of treatments
- Anticipated costs
- The importance of the patient monitoring their health conditions with a Western medicine practitioner, etc.
For more information, see the guidelines stipulated by Chinese Medicine Board of Australia (CMBA).
Informed Consent
Before any treatment, it is essential that the practitioner explains fully in lay terms what is involved. The patients must sign and date an informed consent form, which should be included in the patient history record.
Section 3.5 of the CMBA Code of Conduct states that the Informed Consent Form needs to be comprehensive and written in English. The form therefore should explain:
- the treatment rationale
- pre and post- treatment requirements
- treatment methods
- herbs/acupoints used/formulae/protocol/techniques
- treatment procedures
- possible reactions and/or side effects
- risks involved
- post-treatment care or management and estimated treatment cost.
Most importantly, any high-risk procedures must be brought to the patient’s attention both verbally and in writing prior to treatment. Risky procedures may include fire needling; needling over vital internal organs, laser acupuncture, electro-acupuncture, Tui Na, moxibustion, Gua Sha and cupping where, in some instances, bruising, bleeding, swelling or scarring may occur.
Contingency Plans / Emergency Procedures
If a patient emergency or an adverse event occurs, it is important to have in place a contingency plan or emergency procedures that detail steps to be taken by the practitioner. Depending on the type of event, this may include reporting adverse events to relevant authorities, seeking medical help, calling for an ambulance or arranging for some form of follow-up care.
Whatever needs to be done, it is important that the practitioner demonstrates a high level of duty of care to the patient at all times. The patient should never be left to make their own arrangements.
It is essential to record what happened in an Adverse Event Report. The report should be forwarded to your professional indemnity insurer to alert them about what has happened. This step is very important because the patient could make a claim against you. If the adverse event involves a reaction to herbal medicine or treatment equipment, the Therapeutic Goods Administration should be notified.
Remember, any patient can report you to the Health Care Complaints Commission (HCCC) or Chinese Medicine Council of NSW (CMC) if they are dissatisfied with the treatments you provide. The risk of this happening is particularly high when a treatment leads to an adverse event.
All cases reported to the HCCC are forwarded to the CMC for investigation. If that occurs, comprehensive clinical records, coupled with thoughtful duty of care, may help mitigate complaints brought against you by dissatisfied patients.
Moreover, good record keeping could serve as compelling evidence to help you in any CMC investigation or hearing resulting from alleged breaches of the CMBA Standards and may help reduce the possibility of your being suspended, de-registered or prosecuted.
Prepared by Dr Li Mei-Kin Rees