i agree with gussie's thoughts. what had you written that you didnt want to show?
Rosie, Robyn will confirm this or not, but I got the impression that she hadn't written ANY notes, except for notations on the foot chart, and was therefore discomfited by not having any to show the client. Is this right, Robyn?
Love
Sunanda x
What quick responses, Thank you for both.
Gussie - Thank you for clearing up the DP issue.
However, I'm now a little concerned regarding what I'm writing up for my case studies. We're required to go into a fair amount of detail regarding what we find and the possible explanations / links etc. My case study write-up's have all been very detailed, my first impressions, family details, emotional states, etc. etc. are all quite intensive, I've made detailed links between what I've captured on my consultation forms and what I've charted on the feet. I've provided an array of possible explanations and interpretations and have done so in much detail. I'm trying learn as much as I can from this course.
In a student environment we're expected to go into alot of detail, in practice this doesn't happen and isn't required. For my massage practice I have detailed consultation sheets and very brief notes that I scribble up before and after a treatment, again these are very brief and are completely non-personal - they relate to physical conditions, illness, anything that the client has brought to my attention that I should be aware of or anything that has come up during the treatment. I guess, what I'm saying is I have no qualms about disclosing practice notes, but I do have some real concerns when it comes to my student interpretations and my involved and details analysis of the client's feet.
Knowing that they're entitled to have this information is going to influence what I write up. For example, with Mrs B, my interpretation and first impressions (which we're required to write up about) would be that she was someone who was apparently quite anxious and very cautious, she had her mobile phone in her hand when she first arrived and was asked who else was in the house and if I lived alone. She phoned a number of times on the drive over saying she was lost and had missed a turning because the car behind her was creeping up on her and she couldn't concentrate. I'd detail all of these facts as well as provide links where I could correlate these impressions with what I found on the feet. I'd also include that she went through an early menopause and is deeply saddened that she has no family, that she feels very lonely and has suffered from depression for all of her adult life. I'd try to correlate as much of this back to her feet, drawing links between for example the hard and yellowed skin along her pelvic floor, the deep fissures on both heels and the paper thin and very dry areas on her uterus reflex and her early menopause and subsequent hystorectomy. The charts and notes I scribbled up were very detailed and had I typed up my interpretations and findings for submission purposes it would have contained even more detail and my own personal interpretation. I'm not sure I'd want to share these notes with someone who is clearly and very obviously in an emotionally vulnerable state, or infact with any of my case studies even if they weren't, just because they are my own personal interpretations. I'm just not comfortable with that at all and would restrict the level of detail and intepretation with what I felt was appropriate for the client as my audience.
I think I'm going to hold back on my case study write ups for the time being and discuss this with my tutors, I'm a little concerned that we haven't touched on data protection and the legal aspects and I'd like this brought to their attention.
Thank you again for the clarity you've provided, I've got alot to think about!
Robyn
chin up
we would all be perfect if we wrote our case study notes up immediatly - unlike ordinary treatment notes you have to write a more detailed explaination to show that you understand what you are finding
regarding notes - not that I have every been asked but if any client wanted to see their notes they would have to put the request in writing - some therapists I know also make a small charge for notes - i think it would depend how long the notes are
You can make a charge for providing photocopies of notes, but not for just showing them to the patient.
Again, you'd need consent to allow the notes off the premises (but not if you're handing them directly to the patient, as it's then their responsibility); but no written record is required for showing the notes to the patient.
The level of detail you can go into with the tutor for a case study is (I think) dealt with elsewhere on this site, and may have data protection ramifications. But for your own notes, all the things you said you think about, and note down, are all fair enough. You can even directly insult your patient in your notes if you so choose - as long as you can back up your claims if challenged (I'd also very strongly recommend not doing so, surprisingly enough). Basically, as long as what you write has basis in what you know/believe/suspect, then you can write what you like.
And yes, the case study write ups still count as part of your case notes, and the patient has the right to immediate access on request. It's very rare that someone will want to though, I've never come across it yet.
In response to a couple of points:
1) When Mrs B arrived for her first treatment I spent alot of time explaining to her that i was a student, that I could not diagnose and the treatment was for her to enjoy and experience the benefits of reflexology which she said she understood all about. I told her I would require six treatments which would be written up and submitted to my school for marking. She asked me questions about the write ups and I explained that I would be making notes during the course of her treatment and would later write up my intepretations.
2) We went through the paperwork and Mrs B signed my consultation form, I asked her to complete and sign my shool's consent form which includes a section to be completed with personal details (name, dob, etc) followed by three lengthy paragraphs explaining what reflexology is, and consenting to the treatment. Mrs B filled out the paperwork and I did not notice she had not signed the consent form until after she had left.
3) I made detailed notes on my foot chart and my consultation sheet is very detailed too. I scribbled up what conditions I would present on, what alternative therapy I would recommend, just the basics. I got as far as setting up her case file, and creating templates, I had NOT started the write up, because I am behind with my case study write ups and I believed she would not return for treatment because I'd not had a response back from her the following week. Arguably, I should have and we are meant to write our treatments up right after we've done them, in reality I am a few days behind with a few of my treatment write ups.
4) When she arrived yesterday I was extremely sensitive and professional with regards to the situtation, I lead her into the treatment room and took full responsibility for my misunderstanding regarding the confusion around holiday. The first thing I asked her to do was sign the consent form saying that I'd noticed she'd not signed it last time.
Really, the concern for me is do I have to share what my personal interpretations of my case studies are with my case studies should they ask?
The issue for Mrs B was not that she has the legal right to my notes (which we've established she does) but that she was under the impression (not from myself) that these treatments would be some kind of diagnostic tool for her to identify any health / emotional issues. She is quite entitled to have copies of my consultation form and my foot chart and the preliminary work I've begun, but that is all I have to share with her if she requests this.
Hope this clarifies.
Thanks for all the input.
Robyn