Case study: Changing the treatment plan

Suzanne is an RMT who works out of a home office where she treats three to four patients per day. Her regular patient, Donna, returns for ongoing treatment of chronic low back pain due to osteoarthritis. It has been over a year since Donna’s last visit.

Suzanne takes care to ask Donna if there are any changes or updates to her health history. She establishes a clear treatment plan, charts Donna’s current pain level, communicates benefits and possible risks of treatment, and charts that verbal consent was received to proceed with treatment.

During today’s treatment, Suzanne observes that Donna’s right shoulder is elevated and hyper-toned. Aware of how relaxed Donna is, Suzanne chooses to add the shoulder work into the treatment without obtaining verbal consent from Donna. She completes the treatment, charts changes to Donna’s pain levels as well as the treatment that was provided during Donna’s visit, and continues to her next appointment.

Do Suzanne’s actions meet the consent standard of practice?

Yes and no. Suzanne should have taken time to gain consent to change the treatment plan. New treatment plans require that an RMT revisit, revise, obtain, and document the patient’s informed consent.

It is possible that Donna may have an undisclosed injury to her right shoulder. This would require proper assessment prior to treatment. By failing to obtain Donna’s consent to the new treatment plan, and thereby failing to take a health history and conduct assessments specific to that treatment plan, Suzanne has not acted in her patient’s best interests.

However, Suzanne did meet the requirements of the consent standard of practice in another respect. Suzanne was very thorough with her interview process and charted verbal consent…

Consent standard of practice case studies