Client record keeping is unfortunately one of those dreaded risk management topics. Guild Insurance understands that it isn’t the most interesting of topics for AEPs to spend time thinking and talking about. However, it’s incredibly important, and Guild’s experience suggests many AEPs would benefit from learning more about good record keeping.

Record keeping and insurance claims

Why is an insurer so concerned about record keeping? It’s because client records can greatly impact insurance claims in two ways:

1. Poor records may make a complaint, and therefore an insurance claim, difficult to defend due to the lack of evidence.

2. And surprisingly to some, poor records can contribute to poor or unexpected outcomes following sessions, such as an injury, leading to the client complaining and possibly seeking some form of compensation.

The wellbeing of clients is paramount, therefore reducing the potential risk of injury should be a priority to AEPs.  A potential risk when treating a client is a claim brought against a practitioner, which can lead to insurance claims. This can be a very challenging and confronting experience. Therefore, understanding how to improve the standard of client records really should be a core focus. 

Why keep detailed client records?

Continuity of service

It’s not uncommon to hear professionals say they can remember the details of their clients and any interactions with them. However, at Guild we regularly see examples where professionals haven’t remembered key aspects of their sessions or consultations, and this has led to a poor outcome for the client. It’s therefore imperative to record details about all sessions, with specific information about what exercises were performed and how the client responded to them. It’s also important to be sure you refer to this information within the client’s record when planning future sessions.

Professional expectation

All professionals need to be aware of the various expectations placed on them, which are there to assist people to carry out their work appropriately. And it’s a common expectation that professionals keep detailed records of client interaction. This is no different for AEPs.

In the ESSA Code of Professional Conduct and Ethical Practice, it states that ESSA members and accredited professionals must ‘keep accurate, clear, respectful, up-to-date records documenting services’. This Code can be found at www.essa.org.au/Public/Professional_Standards/ESSA_Code_of_Professional_Conduct___Ethical_Practice

Defence of a complaint

If there’s any allegation of wrongdoing made against a professional, their records are going to be incredibly important. Those records provide evidence of what took place and why when providing services to clients. Without this, the professional will be relying on their memory as a defence. Information recorded at the time of the session is going to hold greater weight as a reliable defence than a professional’s memory months after an event. As the saying goes ‘Good records = good defence, poor records = poor defence and no records = no defence’.

Funding audit

Funding providers, such as private health insurers, regularly review the rebates they pay for services provided and can conduct audits to be sure professionals are billing appropriately. It’s not uncommon for a professional to receive a request from a funding provider to produce records to justify their billing practices.  If the reasons behind the service, and therefore the billing, isn’t clear, funding providers can demand repayment.

What to record?

The key question many professionals ask when it comes to client record keeping is ‘how much detail do I need to record?’.  Exactly what to include can vary according to the specifics of the client’s condition and services provided. However, generally records should include, but aren’t limited to:

• Client identifying details and contact information
• Pre exercise screening information
• Date of the session
• Relevant pre exercise discussion – for example, how the is client feeling and what their expectations are
• Details of the client’s informed consent, including the risks, benefits and potential outcomes that were discussed
• Details of all exercises performed including modifications made to the program and why
• Client’s response to exercises – did they struggle, feel pain or discomfort, are they ready to progress etc
• Any instructions given to the client for exercise outside of the session provided
• Referrals to health professionals or anyone else
  

When a professional is unsure if they‘ve included enough detail, they should ask them self whether or not another professional could read the record and understand the full picture of what took place, without the need to fill in any gaps. If the full story isn’t there, there isn’t enough detail.

Professional and objective

Client records need to always be professional and objective. Constructive critical comments about the client can be included, however this must be professional and only done when relevant to the service being provided. This may occur in situations where the client isn’t able to perform exercises correctly or isn’t complying with instructions when away from session, and this could lead to injuries or a lack of progression. However, it’s important to remember that client records can be accessed and read by several people, including the client, so always be mindful of the language used. The language should match the professional language a professional would use when speaking to the client during a session.

We’re not asking you to check to see if you’ve made a typo... and called yourself Sara instead of Sarah. While this name error is no biggie and might just mean a bit of paperwork to amend it, the name error Guild often sees is only an Insured’s personal name on their policies instead of the legal entity name under which they trade. This error can expose you as the Insured to face the financial consequences of claims made against that legal entity or your employees.

Which name should be listed on my policy?

The name/s you list on your policy are the names that the policy provides coverage for. Think of it this way, if it’s not listed, it’s not covered. Don’t leave yourself exposed to uninsured liabilities by leaving your legal entity (Pty Ltd) off your insurance schedule.

Not sure you have the right name on your policy?

At Guild, we understand that insurance can be confusing which is why we have a dedicated team to help navigate you through it. To update your policy or to discuss your current policy, speak to one of our friendly Insurance Specialists on 1800 810 213.

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All health practitioners would be well aware of their requirements to obtain informed consent from their patients before assessment or treatment takes place.  However, Guild Insurance’s vast experience in managing claims made against health practitioners has highlighted that many practitioners don’t meet all their informed consent requirements.

What is informed consent?

There is an explanation about informed consent in the Code of Conduct for each of the professions regulated by AHPRA.  In this document, informed consent is defined as ‘a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved’.  This statement highlights the difference between consent and informed consent.  If a patient hasn’t been made aware of the benefits and risks, their consent isn’t informed.

Informed consent isn’t just required for treatment. Depending on the nature of the healthcare being provided, informed consent should also be obtained for assessment. 

Informed consent and insurance claims

Informed consent can feature in insurance claims against practitioners in a couple of ways.

It’s not uncommon when a patient is unhappy following treatment for them to allege they weren’t made aware of the risks when they consented to treatment.  Quite often they will allege the treatment was negligent and has resulted in harm or suffering.  They then add that had they been informed of the possible risks, they wouldn’t have consented.

In other cases, patients may not make any allegation about consent, their complaint might solely focus on the clinical outcome, yet when their claim is being managed it’s found that they didn’t give their informed consent prior to treatment being provided.  When this occurs, it makes it challenging for Guild to prove that the practitioner has treated appropriately and met their requirements.

The informed consent conversation

Informed consent requires a conversation between the treating practitioner and the patient.  This conversation needs to occur prior to assessment and treatment. 

The conversation must:

• detail the recommended assessment and treatment as well as alternate treatment options
• include the expected benefits of that treatment
• provide information about the risks of the treatment
• allow time for the patient to ask questions
• be held in language which can be understood by the patient which means practitioners should avoid technical clinical language.
• take place in a private area where the patient will feel comfortable being open and honest about their health situation.
• be tailored to that individual patient and their unique clinical needs

Recording informed consent

It’s imperative that practitioners make a note in the clinical record regarding the patient providing their informed consent.  This needs to be more than ‘IC given’.  The record needs to show what treatment options and risks were discussed as well as any questions asked by the patient.  The record should also show what the patient consented to as well as what they didn’t consent to where relevant.

The informed consent form

One area which leads to some confusion about informed consent is how to use an informed consent form.  Having a patient sign a form is seen as a quick and simplified way of having a patient provide their informed consent and keeping a record of that.  However, they are unfortunately too often used inappropriately. 

Signed forms aren’t a requirement.  While recording consent is required, this doesn’t need to be done using a form.  Notes in the clinical record are sufficient.  However, signed forms do provide additional evidence if there is an allegation that informed consent wasn’t given.

Forms can’t be used to replace the informed consent conversation.  A patient can not read a form and gain the same level of understanding as they would from a conversation with the practitioner.  Nor can they ask questions of the form. 

A form should only be signed after the conversation with the practitioner has been had and the patient understands what it is they’re consenting to.  Patients are occasionally asked to sign consent forms at reception before they’ve seen the practitioner.  As there has been no assessment or discussion about treatment at this stage, this can’t be considered informed consent as the patient hasn’t been informed.

Some practices combine new patient forms with the consent form.  This isn’t ideal as the two forms serve different purposes.  Also, having them on the one form encourages patients to sign the consent form at reception before they’ve seen the practitioner.  Therefore, they should be divided into two separate forms.

Informed consent is not a one-off event

Practitioners regularly ask how often their patients need to give informed consent.  There is no set time frame for when informed consent conversations or signed forms need to be repeated.  The requirement is that when a patient is receiving any assessment or treatment, they need to have given their informed consent to this.  Therefore, informed consent should be an ongoing process; it’s a continual conversation with patients during consultations.  And when there is any change in the treatment being provided, or if the patient has returned following a period of absence, informed consent needs to be revisited.  A general ‘consent to all treatment’ for the life of the therapeutic relationship is not appropriate.

Informed financial consent

As well as consenting to assessment and treatment, patients should also give their informed financial consent.  This means they need to be provided with information about the expected cost of treatment before this treatment commences.

In summary…

There is no one right way to undertake an informed consent conversation and process.  Practitioners must adapt what’s discussed for the patient they’re treating and that patient’s unique circumstances.  However, what must occur in all cases is that the patient is informed of and understands the proposed treatment, alternate treatment options and the risks involved.  Only with this information can they give their informed consent.  The practitioner must also be sure to make a record of this informed consent discussion in the clinical record.

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