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KIN 371- Professional Practice in Kinesiology > Consent and Documentation > Flashcards

Consent and Documentation Flashcards

1
Q

What is consent?

A

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.

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2
Q

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

A

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

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3
Q

General Guidelines of Consent

A

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

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4
Q

What are the components of informed consent?

A

Disclosure
Understanding
Voluntariness
Competence

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5
Q

Disclosure and Informed Consent

A

providing the patient with comprehensive information about the proposed treatment including its purpose, benefits, risks and potential alternatives.

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6
Q

Understanding and Informed Consent

A

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

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7
Q

Voluntariness and Informed Consent

A

confirming that the patient’s decision is made voluntarily, without coercion or undue influence.

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8
Q

Competence and Informed Consent

A

assessing that the patient has the capacity to make the decision
-ie. age, mental health status, conscious vs unconscious, etc.

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9
Q

Basics for Obtaining Consent

A

Clear communication
Assess understanding
Document everything
Respect patient autonomy
Cultural sensitivity
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.

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10
Q

Obtaining Consent: Clear Communication

A

use plain language and avoid medical jargon; consider using visual aids if necessary.

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11
Q

Obtaining Consent: Assess Understanding

A

ask the patient to explain back the information to ensure comprehension.

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12
Q

Obtaining Consent: Document Everything

A

keep thorough records of the consent process, including any questions asked and answers provided.

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13
Q

Obtaining Consent: Respect Patient Autonomy

A

always respect the patients right to make their own decisions regarding their healthcare.

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14
Q

Obtaining Consent: Cultural Sensitivity

A

be aware of cultural differences that may affect the consent process and accommodate the patients needs accordingly

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15
Q

What are the different types of consent?

A

Explicit (written) consent
Verbal consent
Implied consent
Emergency consent

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16
Q

Explicit (written) consent

A

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

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17
Q

Verbal consent

A

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

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18
Q

Implied consent

A

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

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19
Q

Emergency consent

A

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

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20
Q

What are some legal and ethical considerations with consent?

A

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.

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21
Q

Consent for Vulnerable Populations

A

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

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22
Q

HCCFAA in Long Term Care

A

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

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23
Q

Kinesiologist requirements with consent…

A

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.

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24
Q

When can consent be broken?

A

Mental Health Act
Child Protection Act

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25
Q

Mental Health Act and Consent

A

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.

26
Q

Child Protection Act and Consent

A

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.

27
Q

What is documentation?

A

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.

28
Q

SOAP Documentation

A

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.

29
Q

Subjective (S)

A

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.

30
Q

Objective (O)

A

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.

31
Q

Assessment (A)

A

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.

32
Q

Plan (P)

A

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

33
Q

Kinesiologist Responsibility and Documentation

A

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.

34
Q

Best Practices for Documentation

A

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.

35
Q

Retaining Records

A

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.

36
Q

Transferring Records

A

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.

37
Q

Destruction of Personal Records

A

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.

38
Q

Report Writing

A

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.

39
Q

Purpose of Report Writing

A

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.

40
Q

Documentation of patient care

A

Record keeping
Legal protection

41
Q

Record Keeping

A

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.

42
Q

Legal Protection

A

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

43
Q

Communication with Healthcare Professionals

A

Interdisciplinary collaboration
Referral processes

44
Q

Interdisciplinary collaboration

A

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.

45
Q

Referral Processes

A

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

46
Q

Patient Progress Tracking

A

Monitoring progress
Adjusting treatment plans

47
Q

Monitoring Progress

A

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.

48
Q

Adjusting Treatment Plans

A

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.

49
Q

Evidence-Based Practice

A

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

50
Q

Data Collection

A

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.

51
Q

Quality Improvement

A

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

52
Q

Patient Education and Engagement

A

Communication with patients
Setting expectations

53
Q

Communication with Patients

A

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.

54
Q

Setting Expectations

A

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.

55
Q

Professional Accountability and Development

A

Self-reflection
Standardization of care

56
Q

Self-reflection

A

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

57
Q

Standardization of Care

A

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

58
Q

Insurance and Reimbursement

A

Justification for services
Compliance with regulations

59
Q

Justification for Services

A

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

60
Q

Compliance with Regulations

A

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

61
Q

Forms for Reporting

A

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

62
Q

WorkSafe BC

A

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.

KIN 371- Professional Practice in Kinesiology (12 decks)

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