GENERAL
CONTINUING EDUCATION
EXAMS
INSURERS
PROFESSIONAL LIABILITY INSURANCE
STANDARDS OF BUSINESS PRACTICE
The CPC does not endorse any specific email or fax systems/software. However, all systems/software used in the relation to patient care from Pedorthic services MUST be in accordance with PIPEDA and the Provincial Privacy Acts.
What are the main requirements for email and fax communications under PIPEDA and Provincial Privacy Acts?
- Consent: Obtain explicit or implied consent from individuals before collecting, using, or disclosing their personal information.
- Purpose: Clearly state the purpose for collecting personal information and only use it for that stated purpose.
- Accuracy: Ensure the information collected is accurate, complete, and up-to-date.
- Security: Implement appropriate security measures to protect personal information against loss, theft, and unauthorized access.
- Access: Provide individuals with access to their personal information and the ability to correct any inaccuracies.
How can organizations secure email communications?
- Encryption: Use strong encryption methods for sending sensitive information via email.
- Secure Email Services: Employ secure email services that comply with privacy regulations.
- Access Controls: Implement strict access controls to ensure only authorized personnel can access personal information.
- Training: Regularly train employees on secure email practices and the importance of protecting personal information.
What measures should be taken to secure fax communications?
- Secure Fax Machines: Use fax machines located in secure areas to prevent unauthorized access.
- Confirmation: Always confirm the recipient’s fax number before sending sensitive information.
- Cover Sheets: Use cover sheets that do not contain sensitive information and include a confidentiality notice.
- Log Records: Maintain logs of fax transmissions and receipts to ensure accountability and traceability.
To learn more about PIPEDA click HERE
To learn more about the Provincial Privacy Acts click HERE
Clinical records are comprehensive documents that contain all pertinent information regarding a client’s health and medical history. These records are maintained by Canadian Certified Pedorthic Professionals and facilities to ensure continuity of care, facilitate communication among allied healthcare professionals, and provide a detailed account of a client’s health status and treatment over time.
Here are the key components typically found in a client’s clinical records:
- Demographic Information: This includes the client’s name, date of birth, gender, address, contact information, and emergency contacts.
- Medical History: A detailed history of the client’s past pertinent illnesses, injuries, medications (including prescriptions and over-the-counter drugs) etc.
- Clinical Notes: Notes made by Canadian Certified Pedorthic Professionals during consultations, examinations, and follow-up appointments.
- Diagnostic Tests and Results: relevant imaging studies (X-rays, MRIs, CT scans)
- Treatment Plans: Detailed plans outlining the course of treatment prescribed for the client, and follow-up care instructions.
- Consents and Authorizations: Records of signed consent forms for treatments, procedures, and disclosures of medical information to third parties.
- Correspondence: Relevant communications between healthcare providers, as well as communications with the client or their family regarding healthcare decisions and treatment option
A daily appointment record is a document or system used by medical offices to manage and track client appointments scheduled for a specific day. It serves as a centralized tool for organizing client visits, ensuring efficient client flow, and maintaining a structured approach to appointment scheduling.
Here are the key components and characteristics of a daily appointment record:
- Date: The specific date for which the appointments are scheduled. This helps in identifying appointments for a particular day within the healthcare facility’s scheduling system.
- Client Information: Each appointment entry typically includes basic demographic details of the client:
- Name: The client’s full name.
- Contact Information: Phone number or other contact details.
- Appointment Time: The scheduled time when the client is expected for their appointment.
- Appointment Details:
- Reason for Visit: Brief description of the reason the client is scheduled to see the healthcare provider (e.g., new assessment, follow-up visit,etc).
- Appointment Duration: Estimated duration of the appointment, which helps in managing the schedule and client flow throughout the day.
- Provider Information: The name or identifier of the Canadian Certified Pedorthic Professional who will be seeing the client during the appointment.
- Additional Notes: Space for any relevant notes or special instructions related to the appointment, such as reminders for specific tests or procedures, special accommodations needed for the client, or follow-up instructions from previous visits.
- Appointment Status: A record of whether the appointment is confirmed, tentative, canceled, or rescheduled.
Financial records refer to the documentation and records related to the financial aspects of services provided to clients. These records are crucial for healthcare facilities, insurance companies, and clients themselves to track and manage payments, reimbursements, billing, and financial transactions associated with medical care.
Here are the key components typically found in a client’s financial records:
- Billing Statements: Detailed statements sent to clients or their insurance providers outlining the services rendered, associated costs, and payment due. Billing statements include:
- Itemized list of medical services and/or products provided (e.g., assessment, foot orthotics, brace etc).
- Dates of service for each item.
- Charges for each service or product.
- Payment Records: Records of payments received from clients, insurance companies, and other third-party payers:
- Method of payment (e.g., cash, debit or credit card, insurance payment).
- Date of payment.
- Amount paid.
- Any outstanding balances or refunds.
- Insurance Claims and Reimbursements: Documentation submitted to insurance companies to request reimbursement for services and/or products provided to clients covered by insurance plans. This includes:
- Claims forms submitted electronically or on paper.
- Documentation supporting the medical necessity of services provided. Payments received from insurance companies as reimbursement for covered services.
Medical Abbreviations List PDFCharting refers to the process of documenting client information and interactions with healthcare providers. There are several types of medical charting methods used in healthcare settings including:
- SOAP stands for Subjective, Objective, Assessment, and Plan. This format is commonly used in medical charting to organize information systematically:
- Subjective: client’s symptoms, complaints, and history provided by the client.
- Objective: Observations from physical examination, vital signs, and any measurable data.
- Assessment: Healthcare provider’s impression based on the subjective and objective data.
- Plan: Treatment plan, further tests or referrals recommended.
- Problem-Oriented Medical Record (POMR): POMR organizes client information by problems (or diagnoses), each with its own section in the medical record. It typically includes:
- Database: Comprehensive information about the client’s history, symptoms, physical exams, and lab results.
- Problem List: A list of current and past medical problems.
- Initial Plan: Initial treatment plan for each problem.
- Progress Notes: Updates on the client’s progress, responses to treatment, and any changes in the plan.
- F-DAR stands for Focus, Data, Action and Response. Each category represents the following information:
- Focus: The focus is the issue that the Certified Pedorthic Professional addresses when visiting the client. This can be a diagnosis, pain monitoring or health lesson.
- Data: Data is the information about the client’s current status. This can include the client’s vital signs or a noticeable change in the client’s condition or behavior.
- Action: This is the action the Certified Pedorthic Professional takes in response to the data. For example, the Certified Pedorthic Professional might replace a bandage if they noticed it needed to be changed.
- Response: This is the response that the client shows after receiving any treatment. For example, this might include a change in the client’s symptoms after an adjustment to their orthotics.
Canadian Certified Pedorthic Professionals may use any charting method they prefer but should use the same template for all files.
Client refusal refers to a situation where a client declines or refuses a recommended treatment, product, and/or service that has been offered or recommended by a Canadian Certified Pedorthic Professional. Documenting a refusal in the client’s clinical record ensures legal compliance, supports continuity of care, facilitates clear communication among allied healthcare providers, and helps manage risks to both the client and Canadian Certified Pedorthic Professional.
This documentation should include:
- The specific treatment, procedure, or intervention that was recommended.
- Details of the discussion with the client regarding the recommendation, including information provided about risks, benefits, and alternatives.
- The client’s reasons for refusal, if provided.
- Any discussions about potential consequences of refusing the recommended treatment.
Signing an Electronic Medical Record (EMR) involves electronically validating and authorizing entries made in a client’s electronic clinical record. The process varies between different systems. The author, date and time of the entry must be able to be identified and not changed.
Here are the different ways to sign an EMR entry:
- Digital Signature: Use a digital signature that is unique to you and securely stored within the EMR system. This may involve selecting a “Sign” button or checkbox next to each entry.
- Password Authentication: Some systems may require you to re-enter your password to authenticate and confirm your intention to sign off on entries.
- Initial: writing your initials at then end of a note
Understanding types of consent is crucial in navigating provider-client relationships, professional settings, legal matters, and ethical considerations. Clear communication and respect for boundaries are essential to ensuring that consent is properly obtained and respected in all interactions. Common types of consent a Canadian Certified Pedorthic Professional may encounter in their practice includes, but is not limited to:
- Informed consent is the process in which a health care provider educates a client about the risks, benefits, and alternatives of a given procedure or intervention. The client must be competent to make a voluntary decision about whether to undergo the procedure or intervention.
- Expressed consent is clear and unambiguous consent given verbally or in writing, where both parties explicitly agree to engage in a specific activity or interaction. It leaves no room for doubt about the intentions of each party.
- Implied consent not explicitly verbalized but rather inferred from a person’s actions or the circumstances. For example, in some situations, consent might be implied from body language or behavior indicating willingness to engage in an activity.
- Proxy consent is given by someone authorized to make decisions on behalf of another person who may not be able to make decisions for themselves.
- Revocable consent can be withdrawn at any time, even after it has been initially given. This emphasizes that consent should be ongoing and voluntary throughout the duration of an activity.
A clinical impression is the preliminary conclusion made by a Canadian Certified Pedorthic Professional about a client’s medical condition based on the clinical findings, symptoms reported by the client and physical examination results during an assessment. A clinical impression aids the understanding of a client’s condition and planning appropriate next steps in their care.
For example, if a client is experiencing symptoms of posterior tibialis tendon dysfunction and excessive amounts of or prolonged pronation are evident during the gait analysis, the clinical impression may read:
Suspected posterior tibialis tendon dysfunction due to excessive pronation duration during gait, custom foot orthotics recommended to limit excessive pronation.
It is acceptable to keep paper records. You are not obligated to transfer all paper records to an electronic format. However, all paper records must be securely stored, organized and easily accessible.
A clinical record can combine paper and electronic data. However, it is important to cross-reference each component to ensure clarity of the total record and where the most up-to-date information may be found. The record should be safely stored and retrievable over the retention period regardless of the technology used. Attention should be paid to the risks associated with each storage medium and systems implemented to identify and address these risks.
When paper records are converted to electronic format, there is no need to maintain a duplicate copy as long as a complete clinical record can be accessed.
If a billing practice error occurs, notify the client, resolve the error, and document the correction in your financial records. For example, if you overbilled a client for a product, first inform the client of the error, then provide a refund to the client in your financial software and ensure your financial records show the refund.
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A fee schedule is a list or table of fees or charges established by a Canadian Certified Pedorthic Professional or by the establishment that employs them, for specific medical services and/or products. It serves as a standardized reference for determining the cost of services provided to clients.
Fee schedules can be stored in accounting software such as Quickbooks, a point-of-sale system and/or a client management system such as Jane. It can also be posted on a website, but it is not mandatory. It could also be posted physically within a clinic
Examples of allowable discounts include decreased pricing for particular groups (seniors, children). They may be offered due to insurer contracts (government programs such as worker’s compensation or disability recipients). Discounts must be established within the fee schedule and applied to all eligible clients.
Billing Error:
Definition: A billing error refers to an unintentional mistake or oversight in the process of generating and submitting a medical bill or claim for reimbursement.
Examples: Common billing errors include:
- Invoicing errors: Invoicing for incorrect service or amount.
- Data entry mistakes: Typos or incorrect client information.
- Calculation errors: Incorrectly calculating charges.
- Administrative errors: Failure to follow billing guidelines or requirements.
Fraud:
Definition: Fraud involves deliberate deception or misrepresentation to obtain unauthorized financial gain or benefit.
Examples: Examples of healthcare fraud include:
- Billing for services not provided
- Upcoding: Billing for a more expensive service or procedure than what was actually provided.
- False documentation: Falsifying medical records or documentation to support fraudulent claims (such as changing dates or falsifying amounts charged on financial records)
A client review is a true statement of their experience with a particular business and/or Certified Pedorthic Professional published/posted to their own or a third-party platform.
A testimonial is the provision by a Certified Pedorthic Professional of a subjective statement from a client or other individual expressing an opinion about the nature or quality of the Certified Pedorthic Professional’s services or the Pedorthic Professional generally.
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