C. Safety and quality in practice

C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

  1. This should include the ability to:
    1. take and record the patient’s case history, adapting your communication style to take account of the patient’s individual needs and sensitivities
    2. select and undertake appropriate clinical assessment of your patient, taking into account the nature of their presentation and their case history
    3. formulate an appropriate working diagnosis or rationale for care and explain this clearly to the patient
    4. develop and apply an appropriate plan of treatment and care; this should be based on:
      1. the working diagnosis
      2. the best available evidence
      3. the patient’s values and preferences
      4. your own skills, experience and competence
    5. adapt an osteopathic technique or treatment approach in response to findings from the examination of your patient
    6. evaluate post-treatment response and justify the decision to continue, modify or cease osteopathic treatment as appropriate
    7. recognise adverse reactions to treatment, and take appropriate action
    8. monitor the effects of your care, and keep this under review; you should cease care if requested to do so by the patient or if you judge that care is likely to be ineffective or not in the patient’s best interests
    9. recognise when errors have been made, and take appropriate action to remedy these, taking account of the patient’s best interests under your duty of candour (see standard D3)
    10. where appropriate, refer the patient to another healthcare professional, following appropriate referral procedures.
  2. If providing care outside of your usual practice environment, you should note in your records where this took place, and apply the same standards as you would apply in your usual practice, or be able to justify why this was not appropriate.

C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

  1. Records help you to provide good-quality care to your patients and should include:
    1. date of the consultation
    2. patient’s personal details
    3. any problems, symptoms, concerns and priorities discussed with your patient
    4. relevant medical, family and social history
    5. your clinical findings
    6. the information and advice you provide, including a record of how this is communicated to your patient
    7. a working diagnosis and treatment plan
    8. records of consent
    9. any treatment you undertake
    10. any communication with, about or from the patient
    11. copies of any correspondence, reports, test results, etc relating to the patient
    12. clinical response to treatment and treatment outcomes
    13. the location of your visit if outside your usual consulting rooms
    14. whether any other person was present and their status
    15. where an observer is present (for example, a chaperone, peer observer, osteopathic student, or potential student) as well as their status and identity, you should record the patient’s consent to their presence.
  2. Your notes should be contemporaneous or completed promptly after a consultation (generally on the same day).
  3. The information you provide in reports and forms or for any other purpose associated with your practice should be honest, accurate and complete.

C3. You must respond effectively and appropriately to requests for the production of written material and data.

  1. To achieve this you will need to:
    1. produce reports and referrals, and present information in an appropriate format to support patient care and effective practice management
    2. develop mechanisms for storing and retrieving patient information, including financial and other practice data to comply with legal requirements in relation to confidentiality, data processing and storage, and requests for information from patients, healthcare professionals or other authorised parties.

C4. You must take action to keep patients from harm.

  1. You must comply with the law to protect children and vulnerable adults.
  2. You should have an awareness of, and keep up to date with, current safeguarding procedures, including those relevant to your local area, and follow these if you suspect a child or vulnerable adult is at risk.
  3. You should take steps to protect patients if you believe that the health, conduct or professional performance of a colleague or other healthcare practitioner poses a risk to patients. You should consider one of the following courses of action, keeping in mind that your objective is to protect the patient:
    1. discussing your concerns with the colleague or practitioner
    2. reporting your concerns to other colleagues or to the principal of the practice, if there is one, or to an employer
    3. if the practitioner belongs to a regulated profession, reporting your concerns to their regulator
    4. if the practitioner belongs to a voluntary register, reporting your concerns to that organisation
    5. where you have immediate and serious concerns for a patient, reporting the colleague to social services or the police.
  4. In any circumstances where you believe a patient is at immediate and serious risk of harm, you should consider the best course of action, which may include contacting the police or social services (though see standard D5 regarding confidentiality).
  5. If you are the principal of a practice, you should ensure that systems are in place for staff to raise concerns about risks to patients.
  6. You must comply with any mandatory reporting requirements, for example, those related to female genital mutilation (FGM) in England and Wales.

C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

  1. Your practice premises must be clean, safe, hygienic, comfortable and appropriately equipped.
  2. There are detailed requirements in law for health and safety in the workplace. Further details can be found on the website of the UK Health and Safety Executive.
  3. You must have adequate public liability insurance.
  4. You should ensure that you have appropriate procedures in place in the event of a medical emergency.
  5. You should take all necessary steps to control the spread of communicable diseases.