Consent and Documentation

Question 1

What is consent?

Answer 1

Healthcare consent is the process by which a patient voluntarily agrees to a proposed medical treatment after being fully informed of its benefits, risks and alternatives.
Process is crucial for ensuring respect for patient autonomy and an ethical medical practice.

Question 2

What is the Health Care Consent and Care Facility Admission Act?

Answer 2

Act which sets out rules for which a capable adult can give or refuse consent for health care.

Question 3

General Guidelines of Consent

Answer 3

An adult can…
-give or refuse consent on any ground, including moral or religious, even if doing so results in death.
-select a particular form of health care based on any grounds.
-revoke consent at any point
-expect respect for their decision
-expect to be involved in all case planning and decision making

Question 4

What are the components of informed consent?

Answer 4

Disclosure = providing the patient with comprehensive information about the proposed treatment including its purpose, benefits, risks and potential alternatives.
Understanding = ensuring that the patient fully understands the information provided, and uses language that the patient can understand.
-the patient must have the opportunity to ask questions
Voluntariness = confirming that the patient’s decision is made voluntarily, without coercion or undue influence.
Competence = assessing that the patient has the capacity to make the decision
-ie. age, mental health status, conscious vs unconscious, etc.

Question 5

Basics for Obtaining Consent

Answer 5

Clear communication = use plain language and avoid medical jargon; consider using visual aids if necessary.
Assess understanding = ask the patient to explain back the information to ensure comprehension.
Document everything = keep thorough records of the consent process, including any questions asked and answers provided.
Respect patient autonomy = always respect the patients right to make their own decisions regarding their healthcare.
Cultural sensitivity = be aware of cultural differences that may affect the consent process and accommodate the patients needs accordingly.
Remember that obtaining informed consent is a fundamental ethical and legal obligation in healthcare that promotes patient autonomy, enhances trust, and improves overall quality of care.

Question 6

What are the different types of consent?

Answer 6

Explicit (written) consent
Verbal consent
Implied consent
Emergency consent

Question 7

Explicit (written) consent

Answer 7

A signed document indicating the patient’s agreement to the proposed treatment/

Question 8

Verbal consent

Answer 8

Spoken agreement from the patient, typically documented in the medical record.

Question 8

Implied consent

Answer 8

Inferred from the patient’s actions, such as presenting for treatment or complying with the treatment plan in non-emergency situations.
Ie. patient is unconscious

Question 9

Emergency consent

Answer 9

Assumed in situations where immediate treatment is necessary to prevent serious harm or death, and the patient is unable to provide consent.

Question 10

What are some legal and ethical considerations with consent?

Answer 10

Consent must be obtained before any treatment is administered, except for emergencies.
Consent can be withdrawn at any time.
Special considerations may be needed for minors, individuals with cognitive impairments, and patients who speak a different language.

Question 11

Consent for Vulnerable Populations

Answer 11

Vulnerable populations include minors, elderly, cognitive impairment, and significant physical impairment.

Question 12

HCCFAA in Long Term Care

Answer 12

Zero tolerance for abuse or neglect of residence in long-term care facilities.
A kinesiologist must report any of the following to the ministry of health…
-improper treatment or care
-abuse of resident by anyone
-neglect of a resident resulting in harm
-unlawful conduct resulting in harm
-misuse of a residence money
-misue of funding provided to long term care faciltity

Question 13

Kinesiologist requirements with consent…

Answer 13

Obtain and document informed consent prior to application of a kinesiology procedure.
Respect the client’s right to refuse or decline service.
Share in decision making with the client or family.
Actively involve the client and family in developing treatment goals.
Report any abuse of consent.

Question 14

When can consent be broken?

Answer 14

Mental Health Act
Child Protection Act

Question 15

Mental Health Act and Consent

Answer 15

If a person reports that they are planning to harm themselves, have a plan and intend to follow through on the plan.
Kin must ensure the patient gets direct access and accompaniment to the closest hospital.

Question 16

Child Protection Act and Consent

Answer 16

If a kin suspects any child needs protection, they must report to the Ministry of Child and Family Development.
This duty overrides all PIPA regulations.
Failure to do so can result in a fine up to $10,000, six months in jail, or both.
Report must be made if…
-risk or previous risk of harm, sexual abuse, or sexual exploitation.
-risk of deprivation of necessary health care or failure to provide consent for necessary healthcare.

Question 17

What is documentation?

Answer 17

Charting for a kinesiologist is essential practice that ensures accurate documentation of patient assessments, treatments, and progress.
Effective charting helps track patient progress, communicating with other healthcare providers, and maintaining legal and professional standards.
Records must contain identifying information on each page of the document.
-legal name, date of birth, and contact info
Helpful to add in occupation and exercise habits currently.

Question 18

SOAP Documentation

Answer 18

SOAP notes are a structured method of documentation commonly used by healthcare providers to capture patient information, assessments, and treatment plans.
Stands for subjective, objective, assessment, plan.

Question 19

Subjective (S)

Answer 19

Patients description of their condition, symptoms, and relevant history.
Includes quotes from the patient, pain levels, functional limitations, and any pertinent information they provide.
Information from other health care providers.
Record the consent that was acquired.
The referral source if referral was in place.

Question 20

Objective (O)

Answer 20

Observations and measurable data collected during the assessment.
Includes physical examination findings, results of tests, measurements, (ie. range of motion, strength), and other objective information.

Question 21

Assessment (A)

Answer 21

Professional interpretation of the subjective and objective information.
Includes clinical diagnosis, evaluation of the patient’s progress, and any changes in the patient’s condition.
Also, can include treatment intervention given that day, at home exercise plan, patient education, etc.

Question 22

Plan (P)

Answer 22

Detailed plan for treatment based on the assessment.
Includes specific interventions, exercises, frequency and duration of treatment, patient education, and follow-up plans.

Question 23

Kinesiologist Responsibility and Documentation

Answer 23

Maintain complete and legible client records.
-including referrals and any correspondence with client name on each page.
Document about delegated tasks, interventions used, client response to treatment including errors or adverse reactions.
Ensure all Kinesiologist entries are identifiable against other team member notes.
Sign or initial all entries and maintain in chronological order.
Corrections/changes must be struck through and initialed.
-whiting out or deleting information is falsifying the documentation.
Document in either English or French.

Question 24

Best Practices for Documentation

Answer 24

Clarity = document must be legible, whether handwritten or in digital form.
Timeliness = chart as soon as possible after the session to ensure accuracy.
Accuracy and detail = provide comprehensive and precise details to create a clear record.
Confidentiality = ensure all patient records are kept confidential and secure.
Professional language = use clear, professional language and avoid jargon that may not be universally understood
Compliance = follow relevant legal and professional guidelines, including maintaining up to date patient records as required by local regulations and professionals standards.

Question 25

Retaining Records

Answer 25

Storage can be completed via paper or electronically on a computer hard drive, cloud storage, or external drive.
PIPA-BC requires records be kept for 1 year minimum and up to 15 years.
BCAK recommendation is to keep clinical records for a minimum 16 years
-timeframe for minors is 16 years after they turn 19
This retention also applies to a kinesiologist clinical retirement.

Question 26

Transferring Records

Answer 26

When leaving a clinical practice, the original records should be retained by the practicing kinesiologist or the information custodian.
If transferring records from paper to digital, then the digital copy becomes the original and the paper copy can be destroyed.

Question 27

Destruction of Personal Records

Answer 27

When the time comes to destroy a record, it must be done in a secure way that prevents anyone from accessing the files.
Ie. Shredding, complete electronic destruction, and incineration.
Good practice to record the name, date, and means (ie. shredding) of destruction.

Question 28

Report Writing

Answer 28

Report writing is a vital component of a kinesiologist’s role, supporting effective patient care, professional collaboration, legal protection, and the ongoing development of the field.
It ensures that kinesiologists provide high-quality, accountable, and evidence-based services to their patients.

Question 29

Purpose of Report Writing

Answer 29

Documentation of patient care.
Communication with other healthcare professionals.
Patient progress tracking.
Evidence based practice.
Patient education and engagement.
Professional accountability and development.
Insurance and reimbursement.

Question 30

Documentation of patient care

Answer 30

Record keeping
Legal protection

Question 31

Record Keeping

Answer 31

Detailed reports provide a comprehensive record of a patient’s assessment, treatment, and progress over time.
This documentation is essential for tracking the effectiveness of interventions and making informed decisions about ongoing care.

Question 32

Legal Protection

Answer 32

Well-documented reports serve as legal records that can protect both the kinesiologist and the patient in case of disputes or malpractice claims.

Question 33

Communication with Healthcare Professionals

Answer 33

Interdisciplinary collaboration
Referral processes

Question 34

Interdisciplinary collaboration

Answer 34

Kinesiologists often work as part of a multidisciplinary team.
Reports allow for clear communication with other healthcare professionals, such as physicians, physiotherapists, and occupational therapists, ensuring cohesive and coordinated care.

Question 35

Referral Processes

Answer 35

Detailed reports help when referring a patient to another specialist, providing them with the necessary background information to continue or adjust the care plan effectively

Question 36

Patient Progress Tracking

Answer 36

Monitoring progress
Adjusting treatment plans

Question 37

Monitoring Progress

Answer 37

Regular report writing allows kinesiologists to track patient progress objectively.
This is includes noting improvements in range of motion, strength, pain levels, and functional abilities.

Question 38

Adjusting Treatment Plans

Answer 38

Based on progress reports, a kinesiologist can modify or adapt treatment plans to better meet the evolving needs of the patient, ensuring that the interventions remain effective.

Question 39

Evidence-Based Practice

Answer 39

Data Collection
Quality Improvement
If you ever get audited, this shows you are clearly and concisely documenting everything that is going on.

Question 40

Data Collection

Answer 40

Reports serve as a source of data that can be used to assess the outcomes of various treatment approaches.
This data can contribute to evidence-based practice by helping kinesiologists determine which techniques are most effective for specific conditions.

Question 41

Quality Improvement

Answer 41

Analysis of report data can identify trends or patterns that inform quality improvement initiatives within a practice or organization

Question 42

Patient Education and Engagement

Answer 42

Communication with patients
Setting expectations

Question 43

Communication with Patients

Answer 43

Reports can be used to communicate with patients about their progress, goals, and the rationale behind treatment decisions.
This fosters patient engagement and adherence to treatment plans.

Question 44

Setting Expectations

Answer 44

Clear documentation helps set realistic expectations for patient regarding their recovery timeline, potential outcomes, and the importance of their active participation in the rehab process.

Question 45

Professional Accountability and Development

Answer 45

Self-reflection
Standardization of care

Question 46

Self-reflection

Answer 46

Writing reports encourages kinesiolgists to reflect on their clinical decisions, treatment strategies, and patient interactions, promoting continuous professional development.

Question 47

Standardization of Care

Answer 47

Consistent and thorough report writing helps standardize care across different patients and scenarios, ensuring that every patient receives high-quality, evidence-based treatment

Question 48

Insurance and Reimbursement

Answer 48

Justification for services
Compliance with regulations

Question 49

Justification for Services

Answer 49

Detailed reports are often required by insurance companies to justify the necessity of services provided, ensuring that treatments are reimbursed

Question 50

Compliance with Regulations

Answer 50

Proper documentation is necessary for compliance with healthcare regulations and standards, including those set by insurance providers and regulatory bodies.

Question 51

Forms for Reporting

Answer 51

Kinesiologists are often required to fill out legal assessment and treatment forms as part of their clinical workload.

Question 52

WorkSafe BC

Answer 52

Independent provincial agency that aids in compensation (lost wages), prevention, and insuring employers.
Provides benefits, medical care, and rehab after a workplace injury.
IN the event of injury, WSBC is mandated to provide a return to work rehab, compensation, and health care to injured worker.