As RMTs we often spend more time one-on-one with our patients than any other healthcare practitioner. Orthopedic testing is built into our appointment times and we have the opportunity to keep detailed records of changes in our patient’s symptom picture over extended periods of time. Communicating these findings and our interventions with our patients primary physician is not only in our patient’s best interest, but can only help improve the relationship between RMTs and medical doctors. I recently implemented a policy for all new patients in my clinic where a Case Management Report is being sent to their doctor (if they have one) after their first visit. As I was formatting this procedure I wondered what prevented me from doing this in the past. Aside from the fact that I didn’t really know ‘how’ to do it, I wasn’t sure if I was allowed to do it according to PIPA. This will hopefully help answer a few of these questions for you, so that you too can start sending medical reports to your patient’s primary care providers.

Am I allowed to communicate with my patient’s primary physician without first discussing it with my patient?

This question troubled me for some time. Registered Massage Therapists are bound by the CMTBC Bylaws, which stipulate we must abide by Personal Information Protection Act (PIPA). You can find links to these documents in full at the bottom of this page. In short, PIPA states that we may collect, use or disclose personal information about an individual for specified purposes if the organization provides the individual with a notice, in a form the individual can reasonably be considered to understand, that it intends to collect, use or disclose the individual’s personal information for those purposes.

Most of us already have this built into our Intake Forms. My intake form, for example, requires my patients consent to this point:

I authorize the clinic and its associated health professionals to collect my personal and medical information as documented above. In addition, I authorize the clinic and its associated health professionals to communicate with my family doctor and/or referring doctor and/or any other health care professional as deemed necessary for my beneficial treatment. I also understand that my personal and medical information is confidential and will only be disclosed to third parties with my permission.

If you don’t have a consent like this built in to your Intake Form, add one. So long as your patient has agreed to these conditions, you have been given consent to report back to their primary physician as necessary for their beneficial treatment.  If you would like to gain verbal consent as well, go ahead and advise your patient that you would like to send a report to their physician.  I have not had a patient refuse yet!

Who do I report to, and how do I get their contact details?

This one is much easier than I initially thought. Also on your initial intake form, you should ask for the name of your patient’s primary physician (most of us already do). Once you have the physician’s name, you can look up their official contact details on the College of Physicians and Surgeons of British Columbia website here: https://www.cpsbc.ca/physician_search. This search will yield the mailing address and telephone number of the physician.

What exactly do I report?
You do not have to spend hours writing a major report for each new client. The Case Management Plan can be relatively simple, including details below:

• Patient first & last name
• Personal health number
• Date of visit
• Reason for visit
• Areas of involvement
• Contraindications or precautions
• Clinical assessment findings
• Types of care or interventions applied or to be applied
• Any other relevant details
• Ideal treatment frequencies and reassessment dates

You may format your own report anyway you like. For your convenience, I have created a very simple Microsoft Word form you can fill out and then print out, or print out and fill out by hand. You can find this template in the links at the bottom of this page or on my RMT Resources page.   I would recommend either printing this out on your clinic letterhead or attaching a standard cover letter to it that includes all your clinic contact details. JaneApp users note that I have shared a Case Management Plan in the JaneApp chart library as well.  If you print it out in letter format from Jane it will include your clinic information and the patient information as on file.

Once you’ve completed and printed out your report, simply pop it in the mail for the patient’s primary physician.

I hope this helps make it easier for you to start sending off reports to your patients primary physicians. Do feel free to get in touch if you have any questions about this!

Resources:

• CMTBC Bylaws: http://www.cmtbc.ca/legislation-bylaws/cmtbc-bylaws#h2-14
• Personal Information Protection Act: http://www.bclaws.ca/Recon/document/ID/freeside/00_03063_01#section15
• College of Physicians and Surgeons of British Columbia: https://www.cpsbc.ca/physician_search
• Case Management Form Template
• Completed Case Management Sample