On November 2, 2017, the Member attended before a panel of the Inquiries, Complaints and Reports Committee to be cautioned.
The Panel outlined the following concerns relevant to the Member’s practice:
Failure to keep records in accordance with the standards of the profession
The Member was reminded of the importance of keeping complete and legible SOAP notes and cautioned that according to the Standard of Practice for Record Keeping, she was expected to ensure that all records contain:
- subjective information provided by the patient or their authorized representative;
- relevant objective findings;
- proposed treatment plan, including prescriptions and recommendations;
- relevant communications with or about the patient;
- indication of who made each entry and when the entry was made.
Failure to obtain and/or document patients’ informed consent
The Panel reminded the Member about the ongoing nature of consent and the importance of documenting in the file that a discussion regarding consent took place and the patient understood the proposed assessment or treatments and their risks, limitations and benefits. The Member was advised that in order for consent to be “informed”, the patient must receive the following information:
- the nature of the treatment;
- the expected benefits of the treatment;
- the material risks of the treatment;,/li>
- the material side effects of the treatment;
- alternative courses of action; and
- the likely consequences of not having the treatment.
Inappropriate and potentially fraudulent billing procedures
The Panel stated that as a regulated health-care provider, the Member was ultimately responsible for proper billing procedures and was expected to audit invoices and billing practices periodically to ensure that her staff were following expectations set by the College.
The Panel noted that the information collected with regard to this investigation might be indicative of a potential insurance fraud. As the Panel in this case found no direct indication of the Member’s involvement with the billing procedures and altering the patient records, this matter did not warrant a referral for a disciplinary hearing. However, the Member was warned that should a similar concern be raised in the future, the ICRC would likely take stronger action.