When you write up your notes and thoughts there's a clear distinction (although sometimes it can be a fine line ;)) between writing something like (and forgive me cos I'm not that 'up' on reflex.) "I could feel crystals in her left big toe, which would indicate possible issues around the head area. The client had reported having regular headaches, which she believes may be linked to stress at work" to writing something like "I could feel crystals in her left big toe, this links to the head and headaches that the client had mentioned and I feel could be caused by the excess of caffeine the client has been drinking due to stresses of work that she has also reported".
The latter attempts to diagnose the causes which, as you know, you shouldn't be doing, whereas the former keeps to the facts and would be something that you should have no issue with showing the client.
actually, giles, the latter would be perfectly fine... its still not a diagnosis and is looking holistically at cause, which is what we are supposed to do. 🙂 no surprises in too much coffee and stress causing headaches :eek:.
now, if you said "I could feel crystals in her left big toe, this links to the head and headaches that the client had mentioned and I feel it could be caused by the tumour i could "feel" in that area, due to the sensitivity showing up in the toe area" thats a diagnosis!!
as a student, in most cases (i think this case is exceptional and rotten luck) most clients are very intrigued as to our findings and i will always discuss areas of imbalance (crystals/ sensitive etc etc) with clients, there and then. often, they are quite aware of problems in those areas and sometimes have forgotten to mention their sluggish digestion or whatever, so, findings are often no surprise, even when you link the physical aspects with the emotions (crunchy shoulders = weight of the world etc etc).
if findings and interpretations (dont forget to say the magic "it could be") are discussed, then notes will reflect the chat, so no secrets.
Excellent advice from everyone above... the only thing I would add is that while it is potentially a bit more exciting to have an "interesting" case study, ultimately you are better off without this particular woman. AND you've learnt some lessons - so a result all round!
Purple Peach
your point about personal notes at home - dont they have to be available to a client as well?
I would be really uncomfortable if I thought/knew a therapist was writing stuff about me that I did not have access to.
just a thought
BIA in reply to your point, if I made a charge it would be for the photo copying of the notes for the client - not just showing the notes
Yeah, you wouldn't win any favours trying to charge someone for just looking at them unless they had specifically made an appointment to come and see their notes and they were taking up your time just for that purpose.
Mostly you would charge for any copies of the notes the client wishes to take away with them, and you are entitled to do this.
Missing consent forms happen; officially they shouldn't, but they do, and we all sometimes forget to check for them; they're also only part of your defence, the larger part is that the patient voluntarily stayed there and accepted treatment, consent can be implied from that.
I'd be extremely concerned about the option of keeping 2 sets of notes, one for patients to see, and one for your own use. So would any potential solicitors if you were ever in that situation.
I know you're not responsible for diagnosis, but I'd advice that you still think of all your notes as being part of the patient's medical record. This means that you should be able to defend everything you've written in there, and that they should record everything you've done to the patient.
Your case study write up forms a part of your notes too, and should be included there. If the patient tells you something they don't want written down (bearing in mind access to the notes is strictly confidential), then they shouldn't have told you. If it's your own conclusions, then they are your conclusions, and should be kept in the notes, as long as you justify your thought process - I won't try to think of a scenario as I know too little about reflexology to make an appropriate one.
You may not be responsible for diagnosis, but that doesn't mean that you can't draw conclusions, and write them down. It means you shouldn't present that information to a patient as FACT (or supposed fact), and that you should in no way give the impression to the patient that it is a medical diagnosis. In fact, I suggest that you have a moral obligation to draw conclusions, so that you can help the patient stay healthy in the first case - suggesting that a patient's headaches may be linked with their stress levels and caffeine intake is not diagnosis; bit it is conclusion, and one that is fair to draw, and explain to a patient.
In an extreme, you'd be able to conclude a suspicion of cancer; as long as you could point to a source of information that links the findings you have with cancer; but you cannot diagnose cancer. Incidentally, if you do, you would have a moral obligation to report this to the patient's GP (not to the patient, you're not trained in that); though you'd have a hard time of it trying to get him/her to listen to you, and there would be issues of data protection if you haven't got the patient's consent to share information with him/her.