Why the client consultation is so vital
One of the key areas of being a complementary therapist is the consultation process. It is fundamental to everything we do from ensuring the treatment is safe and effective to recording observations and treatment planning. We also record aftercare advice and how we will evaluate that the treatments we are given have been effective. Since the COVID-19 pandemic and lockdown, we have seen that therapists are now sending out the consultation form to new clients in advance as this has cut down the amount of time needed in the therapy room. This is fine but we have to remember that these forms are legal document admissible in a Court of Law should there ever be a complaint. Therefore, as well as informing treatment, they also act to protect the therapist. The more information you record and the more detailed it is, the better. So, send the form out to new clients but make sure that you do go through it with them when you meet and make additional notes in order to be completely thorough.
During the consultation, your job as the therapist is to listen and discover what the client wants and needs. If the client is under the care of a GP or consultant, this should be noted and a form should be given out to get agreement from them that there are no medical reasons why you should not go ahead and treat them. This does depend on the presenting pathology, but liaising with the GP helps to raise your profile as a practitioner and also protects you. We do not ask for permission to treat as the GP will not be trained in your therapy and therefore has no point of reference, but you can ask if they have any concerns from a medical perspective.
You need to explain what you can do for the client at this time and put them at ease, especially if this is their first visit for a treatment. Explain how your therapy works if they do not know. Let them ask questions about the treatment. Your confident explanations will give you credibility. This is the time to build up trust; an important part of the therapeutic relationship.
Before proceeding any further you will need to fill in a treatment record sheet(s). At (Complementary Health Professionals CHP) we do have an agreed template for our members to use and/or adapt into your own style/corporate image. It is available in the member’s are of the CHP website. A record card must be accurate and complete and give information on what treatment was given, oils or other massage media or treatment methodology used with reasons, including any special information that may be needed as reference. You must write legibly because these records are admissible as evidence in a Court of Law. There must be no Tippex used; if you make a mistake, cross it out and initial it.
Complementary Therapists NEVER discuss or give out personal information on their clients and the record cards are marked as private and confidential. Records should also be kept in a secure place, preferably locked or if used on a computer, it must be password protected. We will not divulge any information about our clients without their written consent and only where it would benefit them (i.e., referrals to other complementary practitioners or the GP) and only then with the client’s signed permission. Client’s records should be kept for at least six years for insurance purposes and then destroyed by being shredded or incinerated.
Have you ever been asked by a client why they need to give you so much information or ever had someone be difficult about answering so many questions? When filling out your forms be tactful, and answer any questions as to why you are asking that particular question. Assure the client that this is for their safety and to make sure you choose the right treatment for their particular needs. Remember that you are using this form to build up a whole “holistic” picture of this person and their life in order to best suit their individual requirements as well as safe and responsible as a practitioner.
As stated above, these records are vitally important as they are admissible in a court of law if there is ever a complaint made against you. Therefore, keeping accurate and legible records is essential in order to protect yourself. According to NHS Professionals (2010), The approach to record keeping that courts of law adopt tends to be that ‘if it is not recorded, it has not been done’. Good record keeping helps to improve accountability and shows how decisions related to patient care were made (NMC 2009).
Key things to remember when taking the case:
be clear in your writing - write for meaning. For example, if you ask how the client is feeling and they say fine, don't just right "fine" or "good". Think about it - what does that mean? It shows a lack of being thorough. Ask the client to quantify what good or fine means to them and write that down. People use those words to hide their real feelings because they may not fully trust you. It is you job to make someone feel comfortable enough to tell you how they feel. Once they open up, you can treat them more effectively.
don't leave areas blank in your consultation forms. In a court of law this will be taken as non-action in that you did not bother to ask the question. Instead write that it was "not applicable". Always write something relevant as this is your best defence that you did everything that was required.
Be clear in your writing. If your writing is poor then consider writing in capitals. It needs to be able to be read by someone else in the event of a complaint. Always write in black ink to enable legible photocopying or scanning of documents if required. Obviously, this is not necessary if you are using computer records but remember that the principles of confidentiality and information apply to computer records as they do with all other written records.
write up accurate records of the treatment you gave and why. Be thorough here and don't use jargon. Use reflective practice reports after a series of treatments to evaluate your treatments. You can use these also as CPD evidence.
Document conversations you have had with your clients over the telephone or via email or text if you have given further aftercare advice. All entries need to be dated (day/month/year) and signed.
You need to write up your case notes as soon as possible after treatment so as to be as accurate and thorough as possible.
Records must demonstrate any risks identified or problems that have arisen and the action taken to rectify it.
Remember that any errors are corrected by striking the error through and initialling it. Do not use Tippex.
Of course, when taking the case with your client, as well as being professional you also have to strike the right balance so that your approach and attitude makes your clients feel comfortable with you as well as confident in your abilities. Here are some key characteristics and qualities you need to employ:
* Be caring, as this is what our profession is all about and many of us are drawn into this profession because we care about others and want to help. Never lose sight of this quality no matter how successful you become.
* Empathy – this is another important quality. It means having the ability to share someone else's feelings or experiences by imagining what it would be like to be in their situation. This does not mean that you would ever talk about your experiences as the therapy session is all about the client and not you, but it should enable you to try and put yourself in their shoes and show compassion.
* Honesty – Honesty is always the best policy as the saying goes and people respect you more if you are honest with them. If you don’t know the answer to a question it is best to admit this and go and look it up. Even doctors have to look up medicines and pathologies from time to time. Also be honest about expectations of treatment and if you feel you are not helping a client, refer them on to someone who can.
* Moral – always maintain the moral high ground no matter what life throws at you. Always stick to your principles and keep to your professional code of ethics. Never speak badly about another therapist or another person but appreciate that everyone is on their own unique learning journey.
* Kind – always be kind and considerate to people. It is your kindness in life that will draw people to you that need complementary therapies. You will be amazed how adopting a kind attitude will enhance your clientele.
* Approachable – always be friendly and make people feel like they can talk to you easily without fear or judgement. Remain open and impartial.
* Positive – being positive means being optimistic as well, always seeing the cup half full and being thankful for the good things in life. In today’s modern society it is so easy to get bogged down with the tedious depressing aspects. Always smile and spread some happiness.
* Relaxed – this means that you must always appear calm and happy. You need to get yourself into that state of mind before a client arrives.
v Firm – this is important as you do have to sometimes have the courage to be firm with clients. It may be that you need to insist on a different treatment than the one they booked in for because of a local contraindication or you may have to make a charge for a missed appointment. Sometimes you have to stand your ground but communication is the key here. Always explain your actions calmly and confidently.
* Knowledgeable – you do need to respect the amount of knowledge you have gained through your training but also appreciate that you need to update that knowledge on a regular basis and grow as a person and a professional. We can never know all there is to learn, so make sure you do top up and take CPD courses and join local therapy clubs where you can share case studies and increase your knowledge base on a continuous basis. At CHP, we accredit a wide range of courses and there are often discounts for members. Check these out here: https://www.complementaryhealthprofessionals.co.uk/accredited-course-providers
* Progressive - this really follows on from above as the therapies we practice are all progressive and we need to be too. We need to keep learning new aspects and theory relating to our therapies and we need to be involved in gathering evidence of how the therapy works. Perhaps you could write up case studies for publication.
* Confidence is another key to being successful. If you are calm and confident the client will trust your judgement and follow treatment advice. They will in turn feel confident to refer you to family and friends. Always be confident no matter what you do. Have faith in your abilities and your training but don’t be over-confident or egotistical as that just puts people off!
If you would like to join our amazing, progressive association, please head over to our website where the application form can be completed online. We have a huge number of benefits for members but by being members, you are also supporting the growth of our profession as a whole as we work with various Councils to work together for the benefit of all. We require your qualifications to be at nationally agreed standards, many of which we have been involved in developing, and if you would like us to check these for you in advance, please email them into the office. Equally, we are always happy to give industry advice and if you are looking into training, to give impartial advice and help. Email us at firstname.lastname@example.org.