3.1.4 Further investigation / diagnostic imaging The chiropractor shall: a identify when further investigations are needed and act on this need in the patient’s best interests; b use fur
Clinical practice
Clinical records
Clinical records shall be maintained in accordance with good professional conduct and shall contain relevant and necessary information about the patient and the patient's healthcare (see also Annex A).
Case history
A chiropractor must gather and record both current and historical health information about a patient, encompassing physical, psychological, and social aspects of wellbeing This is achieved by asking targeted questions to the patient, a responsible adult, or a legal guardian, with the goal of obtaining relevant clinical data that aids in diagnosing and developing an effective care plan for the patient.
Patient examination
After obtaining the patient's case history, the chiropractor will conduct a thorough investigation for any signs of disease, abnormalities, or dysfunction This examination will involve various methods, including physical examination procedures and specific orthopedic, neurological, and chiropractic tests as deemed necessary.
Further investigation / diagnostic imaging
Chiropractors must recognize when additional investigations are necessary for the patient's well-being and utilize these investigations to enhance patient management They are responsible for conducting or interpreting the results of these investigations, or referring the patient for appropriate assessments if needed Additionally, it is essential to document the outcomes of these investigations in the patient's record.
Clinical decision making and diagnosis
A chiropractor is responsible for evaluating a patient's health status and needs through case history, physical examination, and additional investigations They must formulate and document a working diagnosis or differential diagnosis, along with a rationale for care, which is continuously reviewed during treatment The chiropractor interprets all available information to make informed decisions regarding the patient's health and monitors changes over time Additionally, they consider the natural history and prognosis of any presenting complaints or emergencies, focusing on preventing recurrences and managing long-term healthcare needs.
Plan of care
Chiropractors are responsible for creating a personalized care plan that aligns with the patient's preferences and encourages active participation in their health improvement This plan must have clear objectives and be safe, appropriate, and consistent with the patient's health needs Additionally, chiropractors should possess a thorough understanding of the theoretical foundations of their care and demonstrate competence in its application, ensuring that their practices are evidence-based Informed consent from the patient is essential for the care provided, and chiropractors should regularly assess the effectiveness of the care plan in achieving its goals.
Referrals
A chiropractor should refer a patient to another qualified healthcare professional when it is evident that the patient is either not suitable for chiropractic treatment, needs further investigation or care, or is not improving, experiencing a decline, or has developed new symptoms beyond the chiropractor's expertise.
Referrals must be documented in writing or communicated verbally, clearly outlining the reason for the referral, the chiropractic care provided, and any pertinent details regarding the patient's health It is essential to record these referral details in the patient's medical record.
Use of equipment
All medical devices used by chiropractors shall be CE-marked [7]
In case of X-ray equipment, management shall fulfil Council Directive 96/29/Euratom [8]
A maintenance record shall be kept for each piece of equipment or device.
Core competencies
a) The chiropractor shall have knowledge and understanding of:
1) normal structure and function of the human body;
2) aetiology, pathology, symptoms and signs, natural history and prognosis of neuromusculoskeletal complaints, pain syndromes and associated conditions presenting to chiropractors, including the psychological and social aspects of these conditions;
3) evaluation of the health and health needs of a patient, including common diagnostic procedures, their uses and limitations, and appropriate referral procedures;
4) management of neuromusculoskeletal conditions using manual therapies, physical rehabilitation, general nutritional advice, and the principles of health promotion and disease prevention;
5) scientific methods to provide and understand the evidence-base for current chiropractic practice, and to acquire and incorporate the advances in knowledge that will occur throughout professional life;
6) history, theory, philosophy and principles of chiropractic practice in a contemporary context, including the biopsychosocial model of illness, its limitations, and its role in the healthcare setting;
7) principles of ethics related to chiropractic care, legal responsibilities and codes of professional conduct and practice;
Professional accountability in chiropractic practice involves a commitment to safeguard and advance patient interests, ensuring that practitioners do not misuse their authority, prevent psychological dependence, and uphold patient trust Additionally, chiropractors must cultivate specific competencies to effectively fulfill these responsibilities.
1) ability to obtain appropriate consent before assessing individuals and for providing chiropractic care;
2) ability to take a comprehensive and problem-focused case history and perform an accurate physical examination;
3) ability to integrate case history, physical examination and diagnostic imaging to arrive at an appropriate diagnosis and/or differential diagnosis;
4) ability to interpret diagnostic procedures and make an appropriate response;
5) ability to select appropriate clinical skills and to formulate a management plan in concert with the patient;
6) ability to apply appropriate clinical skills in the treatment of a patient, and to provide information and advice for recovery and continued health;
7) ability to communicate clearly with patients, their families, other healthcare professionals, and the general public, and to ensure patients are fully informed of their treatment choices and care;
The chiropractor must possess the ability to critically interpret scientific evidence and effectively locate and utilize healthcare-related information Additionally, they are required to demonstrate essential skills that ensure safe and competent chiropractic practice.
1) recognition that the chiropractor’s primary professional responsibilities are the health and care of the patient;
2) respect for the values and attitudes of the patient, and a commitment to patient-centred care;
3) commitment to safe and ethical practice, and to maintain standards of chiropractic practice at the highest possible level throughout professional life;
Recognizing the importance of understanding their own knowledge, skills, and experience is crucial for healthcare practitioners When faced with conditions that surpass their ability to manage safely and effectively, it is essential for them to refer patients to other qualified healthcare professionals.
Recognizing the importance of lifelong learning, professionals must consistently update their knowledge and skills This commitment to continuous quality improvement enhances their practice and fosters the generation of new knowledge, while also contributing to the education of their colleagues.
6) willingness to work in the wider healthcare context, and in a team with other healthcare professionals
Undergraduate chiropractic education
The chiropractor shall have a formal, comprehensive undergraduate chiropractic education of a minimum of five years full-time or equivalent
NOTE An example of a suitable framework for undergraduate chiropractic education is provided by the European Council on Chiropractic Education (ECCE) [10] (See also Annex B.)
Graduate education programme
The Graduate Education Programme (GEP) is designed to follow the successful completion of an undergraduate program, marking the transition from supervised practice to independent professional practice This clinically-based program lasts a minimum of 12 months and aims to equip graduates with the necessary skills and knowledge for autonomous practice.
1) maintain and improve on best and safe chiropractic care for lifelong, self-directed learning for continued professional development;
2) further professionalism (i.e., knowledge, skills, attitudes and behaviour expected by patients and society) b) During the graduate education programme the graduate should:
1) demonstrate a defined body of knowledge, understanding, clinical and procedural skills, as well as professional attitudes for providing effective, patient-centred care;
2) show that they effectively facilitate the chiropractor-patient relationship and the dynamic exchanges that occur before, during and after the chiropractic encounter;
3) show that they effectively work within a healthcare team to achieve optimal patient care;
4) demonstrate that they are an integral participant in the provision of healthcare;
5) show responsibility to use their expertise and influence to advance the health and wellbeing of individual patients, communities and populations;
6) demonstrate a lifelong commitment to reflective learning as well as the creation, dissemination, application and translation of chiropractic/medical knowledge;
Demonstrating a commitment to the health and wellbeing of individuals and society is essential through ethical practices, profession-led regulation, and maintaining high personal standards of behavior The graduate education program should reflect these values.
1) encompass integrated practical and theoretical instruction;
2) guarantee best and safe care by deliberate practice and valid feedback.
Continuing professional development
Continuing professional development (CPD) is essential for chiropractors, promoting lifelong learning and enhancing healthcare services for patients while helping practitioners reach their full potential Chiropractors are required to complete a minimum of 30 hours of learning activities annually, with at least 15 hours dedicated to collaborative learning with colleagues or other professionals through various formats such as courses, lectures, and peer reviews Additionally, chiropractors must maintain their own CPD records and take responsibility for reflecting on their learning interests and needs to ensure they are effectively met.
Healthcare delivery relies on trust, assurance, and safety Chiropractors hold a trusted position in society, earned through their education and experience, which also brings the responsibility to adhere to professional standards The Code of Ethics outlines the principles and values guiding chiropractors in their healthcare practice While intended for chiropractors, this Code also informs the public about what to expect from these professionals and the limits of their practice.
Chiropractors must prioritize patient wellbeing, which influences their scope of practice by imposing limitations on behaviors and practices Consequently, the nature and delivery of chiropractic care should align with this fundamental value.
The Code acknowledges the diverse legislative frameworks and regulatory processes governing chiropractic practice across various jurisdictions In countries with statutory regulation, this Code does not override the existing Codes of Practice and Standards of Proficiency For jurisdictions lacking statutory regulation, it is advisable to adopt this Code to maintain a consistent minimum standard across European states.
NOTE See Annex C for further details
Practical organisation of clinic facilities
Chiropractic care facilities must be structured to enable health personnel to fulfill their legal responsibilities effectively Additionally, these facilities should implement systems to identify and address deficiencies, thereby enhancing the quality of care Furthermore, it is essential that these facilities are designed to ensure accessibility for individuals with disabilities.
Facility requirements
General
The clinic in which chiropractors practice may vary considerably in size, position and environ in accordance with national requirements and legislation.
Clinic and hygiene
The clinic maintains a high standard of cleanliness, with documented hygiene procedures strictly adhered to throughout the facility Each area is designed to provide a comfortable working temperature and adequate ventilation, ensuring patient comfort Additionally, all rooms are equipped with soundproofing, low ambient noise levels, and ample lighting to enhance the overall experience.
The facilities of the clinic should meet professional standards.
Access to the clinic
The chiropractor must be easily reachable through recognized communication channels, and the clinic should have clear signage for those seeking to utilize its services Additionally, it is essential that the facility is accessible to individuals with disabilities.
Reception and waiting areas
The reception and waiting area must include a reception desk and ample seating to accommodate the expected number of patients and their companions It is essential to design the space to ensure patient comfort while providing private information whenever feasible.
The prices for treatment shall be clearly displayed
A written complaints procedure shall be available for the patient on request
The clinic shall give access to drinking water.
Toilet
There should be facilities for disabled available, whenever possible.
Consultation and treatment room
Consultation and treatment rooms must be spacious enough to facilitate the easy movement of both the chiropractor and the patient Additionally, these rooms should be equipped with a desk and seating for the patient, along with space for a companion or chaperone.
The consultation and treatment rooms must be adequately sound-proofed to maintain the confidentiality of discussions, while spaces designated for exercise or group activities should be spacious enough to comfortably support the intended activities.
Any facility for dressing/undressing shall be large enough for the comfort of the patient, with direct access to the treatment room and the privacy of the patient ensured
A wash hand basin shall be readily accessible.
Equipment requirements
Equipment
To ensure effective chiropractic services, the essential equipment includes a treatment table with a clean paper or textile cover for each patient, as well as necessary examination tools.
1) Instruments required for proper examination and treatment shall be readily available
2) Anatomical models and/or other patient education materials should be available.
Maintenance
The chiropractor shall ensure that all equipment (see 3.1.8) is maintained in accordance with manufacturers' recommendations Maintenance records shall be kept.
Incident reporting and learning
Where they are available, the chiropractor should engage in chiropractic and/or multidisciplinary patient incident reporting and learning systems.
Quality assurance
a) The chiropractor should review the effectiveness of services they provide This may be achieved by participation in relevant quality assurance programmes
Chiropractors must implement a written complaints procedure that is easily accessible to patients, ensuring that any complaints or claims are addressed promptly and fairly Patients should be informed of their right to escalate unresolved issues to the appropriate authority For further details on quality management system standards, please refer to the Bibliography [2], [3], and [4].
Insurance
Chiropractors are required to maintain professional indemnity insurance to protect against potential liabilities to patients arising from their practice Additionally, they must have employers and public liability insurance to safeguard their practice, employees, and the public in case of any claims.
Professional association membership
The chiropractor is strongly encouraged to join a national chiropractic association
Duty to keep patient records
Chiropractors are required to maintain detailed patient records in the official language of the country, ensuring that these records are securely stored, either in paper or electronic format, and accessible only to authorized personnel Additionally, it is essential for chiropractors to establish protocols for the safe-keeping and secure storage of patient records when they cease practice or in the event of their passing.
Content of patient records
Patient records should contain the following information:
1) patient’s name, address, date of birth, contact details, marital status, gender, occupation;
2) if the patient is not competent to give consent, the name and status of the person giving consent;
3) notification if treatment or advice is given in contradiction with clinical guidelines;
4) advice given to the patient;
5) reason a patient has required access to records or required corrections of records;
6) information given to or received from other healthcare providers, institutions, laboratories, insurance companies, police, child welfare, etc.;
8) notes on sick leave, reports
Patient records should be an accurate reflection of each clinical encounter and should include any factors relevant to the patient’s ongoing care, including their general health
Chiropractic records must be clear and comprehensible for any chiropractor who may take over the patient's care Additionally, it is essential to store these records securely, adhering to local legal requirements.
Correction of patient records
Any errors within a patient record should be corrected by the addition of the correct information without deletion of any previously entered information and noting the source of the correction
General
1) curriculum model and educational methods;
3) behavioural and social sciences, ethics and jurisprudence;
7) curriculum level, structure and composition
B.2 Curriculum model and educational methods
A chiropractic institution must establish a curriculum model and educational methods that align with its objectives, fostering student responsibility for their learning This approach should equip students for lifelong, self-directed learning throughout their professional careers.
Curriculum models should include discipline, system, integrated, problem or case-based learning models, using organising principles such as themes and domains
Effective instructional methods should integrate both the transmission of factual knowledge and the development of critical analysis, inquiry, and problem-solving skills The curriculum must promote active participation and self-directed learning, emphasizing that education extends beyond traditional didactic models.
Teaching and learning methods should be diverse and include a variety of methods, e.g prosection (or dissection), computer assisted methods, and large and small group classes
The curriculum and educational methods should foster life-long learning skills and an appreciation of the need to undertake CPD
The chiropractic institution must outline the course content that informs both staff and students about the anticipated learning outcomes at each stage of the program Additionally, it should detail the integration level between basic sciences and clinical sciences.
— the theory of chiropractic and the scientific method;
— the theory and principles of chiropractic practice, other forms of research inquiry and evidence-based practice, including analytical and critical thinking
The curriculum should include elements for training students in scientific thinking and research methods
Theory of chiropractic should include concepts and principles of practice, and the role of empirical evidence in informing chiropractic knowledge
Training in scientific thinking and research methods should include the use of research projects (or equivalents) to be conducted by chiropractic students
The chiropractic curriculum must cultivate the skills necessary for professionals to engage in scientific advancements and stay informed about emerging knowledge This includes fostering an appreciation for research inquiry and equipping students with the ability to identify, locate, and critically assess information, particularly research evidence.
The chiropractic curriculum must incorporate essential contributions from the basic biomedical sciences to enhance knowledge and understanding relevant to chiropractic practice.
The basic biomedical sciences should include anatomy, biochemistry, physiology, biophysics, molecular biology, cell biology, genetics, microbiology, immunology, pharmacology, pathology and biomechanics
As basic science teaching is relevant to the overall objectives of the chiropractic curriculum; its relevance should be apparent to students
Sufficient integration of the biomedical sciences with the clinical elements of the programme should be ensured, highlighting the relevance of the basic sciences to clinical practice
Basic science and clinical tutors should collaborate in combined teaching sessions based around clinical problems.
Behavioural and social sciences, ethics and jurisprudence
The chiropractic curriculum must incorporate essential elements from behavioral and social sciences, ethics, scope of practice, and legal requirements to enhance effective communication, clinical decision-making, and ethical practice.
Behavioural and social sciences should include:
1) psychology, sociology, and the biopsychosocial model of chronic pain and non-specific neuromusculoskeletal pain conditions;
2) aspects of patient-centred care models, practitioner-patient encounters and oral and written communications skills, and the transferable skills including IT and reflective practice skills;
3) all aspects regulating professional practice including legal requirements, requirements of local national regulatory bodies and codes of ethical practice;
4) other areas of professional practice including management and administration issues and current practice models in a multidisciplinary healthcare setting;
5) ethical practice including the principles of clinical governance, clinical audit, clinical guidelines, and risk assessment and management.
Clinical sciences and skills
The chiropractic curriculum must incorporate essential contributions from clinical sciences to ensure that students develop adequate clinical knowledge and skills for effective practice in a primary contact setting.
The clinical sciences encompass a wide range of disciplines, including general diagnosis, diagnostic imaging, and various diagnostic procedures such as physical, clinical, and laboratory assessments Key areas of focus include orthopaedics, obstetrics and gynaecology, paediatrics, geriatrics, nutrition, dermatology, and pathological anatomy Additionally, the field covers neurology, spinal analysis with motion palpation, as well as manipulative, mobilization, and supportive techniques, all of which are essential for effective rehabilitation.
To reflect the most common conditions treated by chiropractors, the curriculum should emphasise pain management, particularly as it relates to neuromusculoskeletal conditions
Clinical skills encompass a range of essential competencies, including diagnostic imaging, history taking, and physical examination Additionally, they involve performing procedures and investigations, effective communication, and executing treatment procedures Patient care and management, along with providing advice and education, are crucial components, as well as focusing on disease prevention and health promotion.
Clinical skills should include competency in general diagnosis and referral procedures consistent with scope of practice in a primary contact setting.
Clinical training
Chiropractic institutions must incorporate a period of supervised clinical training to ensure that students can effectively apply their clinical knowledge, communication skills, and ethical understanding in practice This training is essential for preparing students to take on appropriate clinical responsibilities upon graduation Additionally, early patient contact is crucial for students, as it fosters their involvement in patient care from the outset of their education.
The curriculum must include a substantial duration dedicated to one-on-one patient interactions, ideally spanning at least one academic year This clinical training phase allows students to serve as primary contact practitioners in a supervised outpatient setting, fostering the development of essential clinical competencies and sound clinical judgment.
To ensure students are well-prepared for safe and competent practice as primary contact practitioners, they must complete at least forty comprehensive new patient assessments, with a maximum of five being direct clinical observations Additionally, a minimum of four hundred treatment visits across a diverse case mix of patients is essential This training period is crucial for developing the clinical sophistication necessary for entering practice and for engaging in postgraduate training.
This period of training should reinforce issues of good record keeping, teamwork, communication with other healthcare practitioners, responsibilities of clinic management, ethics and jurisprudence
This period of training should reinforce issues of self-evaluation through reflective practice, self-directed learning principles and an appetite for life-long learning
The importance of tutor role models and the influence of standards in chiropractic practice set at this stage should be recognised in the clinical training facility offered to students
Close supervision of students, which is of paramount importance at this stage, should include formative and summative feedback mechanisms
A clinic observation program is essential for students to witness clinical procedures firsthand, learn from seasoned professionals, and sustain their motivation to pursue a career in chiropractic.
Assessment methods and regulations
The chiropractic institution must clearly define and document its assessment methods, including criteria for progression and appeals procedures It is essential to regularly evaluate these assessment methods and develop new ones as needed.
When defining assessment methods, it is essential to consider the balance between formative and summative assessments, the frequency of examinations and tests, and the ratio of written to oral examinations Additionally, the approach should include both normative and criterion-referenced judgments, the incorporation of specialized examination types such as objective structured clinical examinations (OSCE), and the involvement of external examiners.
The evaluation of assessment methods must focus on their effectiveness in promoting learning, as well as the quantity and quality of these methods It is essential to assess the reliability and validity of evaluations, particularly concerning clinical skills and competencies.
The assessment principles, methods and practices should be appropriate to the educational aims and objectives, and promote appropriate learning practices
Assessment methods and assessment criteria should be made known to students at the outset of the programme, or course component, and clearly reflect the course objectives
The number of assessments should not require excessive amounts of learning of detailed information to the detriment of time to reflect and assimilate the material
The type of assessments should encourage an integrated approach to learning, and encourage material delivered earlier in the programme to be revisited at later stages
All students must undertake an undergraduate research project that aligns with their degree level This project should involve a research inquiry in a specific topic area, utilizing either qualitative or quantitative methods Regardless of the project's design, it must demonstrate clear evidence of critical thinking and a thorough evaluation of existing research and the project's findings.
Curriculum level, structure and composition
The chiropractic institution must outline the course content, duration, and sequencing to inform both staff and students about the expected learning outcomes at each stage of the program, as well as the degree of integration between basic sciences and clinical sciences.
Chiropractic programs vary in their entry requirements based on previous educational experiences, but they must consist of at least five full-time academic years of study.
In terms of academic credits, this is equivalent to 300 credits where 60 credits equals one academic year The clinical training period should also be delivered on a full-time basis
The duration and modes of delivery of the programme should satisfy national requirements for graduates to practise as a chiropractor
Integrating disciplines through both horizontal and vertical approaches in the curriculum can significantly enhance student learning by illustrating the connection between program content and future chiropractic practice Additionally, it is essential to provide opportunities for students to revisit and deepen their understanding of previously covered material throughout the program.
The curriculum must focus on fostering self-directed learning while providing students with opportunities to explore their specific interests, such as through research projects or similar initiatives.
All courses within the curriculum should have explicit learning outcomes in terms of the level of knowledge and understanding, skills and attitudes expected on completion of the course
Working with patients
Good clinical care
a) Good clinical care should include the following:
1) adequately assessing the patient’s condition, taking account of the case history, the patient’s views and, where necessary, examining the patient;
2) providing or arranging advice, investigations or treatment where necessary;
3) the chiropractor should not misrepresent the gravity of a patient’s condition;
4) referring to another healthcare professional when this is in the best interests of the patient b) When the chiropractor provides care they should do so:
1) within the limits of their competency;
2) with regard to the fact that the welfare of the patient is paramount;
3) in keeping with evidence-based care;
4) with a view to improving health and quality of life c) The chiropractor should ensure that their records are accurate, legible and attributable They should be an accurate reflection of the clinical encounter and should include any factors relevant to the patient’s ongoing care, including their general health All records should be understandable to another chiropractor who may be called upon to assume the care of the patient Records should be stored securely in accordance with local legislation d) The chiropractor should respect the right for patients to seek a second opinion, either from another chiropractor or from another health professional.
Health promotion and self care
Chiropractors play a vital role in promoting self-care among patients by providing guidance on effective self-help measures They should actively support health promotion initiatives that empower individuals to take charge of their health, thereby reducing dependence on healthcare professionals This includes educating patients about how their lifestyle choices can significantly affect their overall health and wellbeing.
Raising concerns about patient safety
Chiropractors must prioritize patient safety and report any concerns to the relevant authorities after thoroughly investigating the facts Additionally, it is essential for chiropractors to document these concerns and the measures taken to address them.
Equality and diversity
Chiropractors must adhere to legal standards to guarantee equitable access to evaluations and treatments, ensuring that they do not discriminate based on color, race, age, disability, ethnic origin, lifestyle choices, gender, sexuality, marital status, socioeconomic status, religion, or beliefs.
Keeping up to date
Chiropractors must continuously update their skills and knowledge throughout their careers, staying informed about practice and clinical guidelines that influence their work Compliance with relevant codes of practice is essential, as is collaboration with colleagues and patients to enhance care quality Conducting clinical and practice audits allows chiropractors to assess their effectiveness and make necessary adjustments when specific interventions are not yielding positive results.
Teaching, training, appraising and assessing
Chiropractors involved in teaching and training must provide accurate information and clearly distinguish unverified theories from established research As educators, they should cultivate the skills and practices necessary for effective teaching Additionally, when reporting on colleagues, chiropractors must maintain honesty and objectivity, avoiding unfair criticism or language that could undermine a colleague's character or integrity.
The chiropractor-patient partnership
To enhance the chiropractor-patient relationship, it is essential for chiropractors to be polite and considerate, demonstrate respect for cultural differences, and treat each patient with dignity Additionally, recognizing the individuality of each patient, respecting their privacy and right to confidentiality, and supporting them in maintaining their health are crucial elements in fostering a positive and effective therapeutic environment.
Communicating with patients
Clear communication is essential in the chiropractor-patient relationship, encouraging patients to take an active role in their care Chiropractors must consider any special needs, such as physical or learning disabilities, when communicating They should clearly explain the treatment process, including relevant risks, benefits, and alternative care options before starting treatment Additionally, chiropractors must inform patients about how their information will be recorded, stored, and who will have access to their records, ensuring confidentiality in compliance with data protection legislation A documented complaints procedure should be in place, allowing patients to voice concerns about their care Patients should also be informed about care arrangements in the chiropractor's absence and who is responsible for their day-to-day care If work is delegated to others, patients need to understand the roles and responsibilities involved Finally, patients should be made aware of the necessity of sharing information for effective care and the implications of declining consent for information sharing.
Communicating with other health professionals
Chiropractors must communicate effectively with general medical practitioners and other health professionals from whom they receive referrals, ensuring that all relevant information is shared with the patient's consent They should respond promptly to other health professionals when a referral is necessary and maintain clear, comprehensive records in emergency situations to clarify their role in patient care Additionally, chiropractors are responsible for providing all pertinent information for any further diagnostic investigations required.
Preparing reports for third parties
When third parties require reports, it is essential to obtain the patient's consent for information disclosure The information shared must be strictly limited to what the third party has requested Additionally, chiropractors should clarify the purpose of the information request and engage in a discussion with the patient regarding it.
Children and young people
Chiropractors must prioritize the health and wellbeing of children and young people, taking action when their rights and welfare are compromised Effective communication is essential, as chiropractors should tailor their information to ensure understanding Additionally, it is crucial to recognize when a chaperone, such as a parent or guardian, should be present during assessments or care, particularly for minors, unless explicit consent is obtained for a private consultation.
Vulnerable adults
Chiropractors must prioritize the wellbeing of vulnerable patients by assessing their health and circumstances, ensuring that care is provided safely They should evaluate patients' capacity to comprehend information and the validity of their consent When working with vulnerable adults, it may be necessary to have another person present during assessments and care Additionally, chiropractors must refrain from exploiting patients' vulnerabilities by sharing personal beliefs or views that could cause distress or discomfort.
Dealing with relatives, carers and partners
Chiropractors must show compassion towards the family and close associates of patients, offering sensitive support and information, even in the aftermath of a patient's passing Additionally, they should prioritize patient confidentiality and carefully consider the consequences of sharing any patient-related information with others.
Openness and honesty
General
Chiropractors must maintain transparency with their patients, ensuring they do not misrepresent the severity of a patient's condition or withhold critical information that could affect the patient's decision regarding assessment or care, including potential risks and side effects of treatment All information should be customized to meet the specific needs of each patient and delivered with their best interests in mind Additionally, chiropractors should acknowledge when a patient's condition exceeds their scope of practice and communicate this openly and honestly to the patient.
Maintaining trust in the profession
Chiropractors must maintain professional boundaries and should never exploit their position to engage in sexual or inappropriate relationships with patients or their acquaintances This includes refraining from any sexualized language or gestures.
Where a chiropractor finds they are sexually attracted to a patient or the patient is sexually attracted to them, they should immediately seek alternative care for the patient.
Consent
Consent is a continuous process rather than a single event Chiropractors must maintain open communication with patients during their clinical interactions and ensure privacy to support this ongoing dialogue.
Chiropractors must provide patients with clear and accessible information regarding their assessment and care options, enabling them to actively participate in their treatment decisions Valid consent requires that patients fully understand the information presented about proposed assessments or care.
The chiropractor should be satisfied they have the valid consent of the patient (or someone able to act on their behalf) before they proceed with:
— involving the patient in teaching or research
The chiropractor should not use their professional position to persuade a patient to consent against their will
Patients should receive comprehensive information to make informed decisions regarding their assessment and care, including the purpose and necessity of any assessments, the diagnosis, and the proposed treatment options They should be made aware of the available care options, the likely outcomes with or without treatment, and any foreseeable risks and benefits It is essential to inform patients about who will be responsible for their care, the reasons for any referrals to other health professionals, and the potential involvement of additional healthcare providers Additionally, patients should know if their care is part of a research program and understand the financial implications of the recommended treatments.
Chiropractors must operate under the assumption that patients are competent to make their own decisions, unless there is clear evidence to the contrary It is essential for chiropractors to take into account various factors that could impact a patient's ability to provide informed consent, such as language barriers and physical or learning disabilities.
Unexpected choices by patients do not necessarily indicate incompetence or an inability to give consent Instead, they may suggest the need for additional information to be provided It's important to note that a patient's capacity is 'decision-specific', meaning they may be able to make certain decisions while struggling with others.
If there is any doubt as to whether a patient has the capacity to consent, advice should be sought from a suitably-qualified health professional
The chiropractor should exercise their professional judgement in assessing the capacity of children and young people to give consent to assessment and care
The chiropractor should understand and comply with the legislation in their jurisdiction in relation to issues surrounding consent and young people.
Providing access to patient health records
When a patient requests access to their personal health records, it should not be unreasonably withheld NOTE Patient health records are subject to European data protection [9]
Where statutes include provisions for access to medical records, the chiropractor should ensure that they are familiar with relevant legislation and comply promptly with any requests for access.
Confidentiality
Chiropractors must uphold patient confidentiality consistently, safeguarding personal information, health details, healthcare requirements, management plans, and any disclosures made during assessments and treatment.
Chiropractors must prioritize patient confidentiality and avoid practices that could jeopardize this duty In situations where confidentiality cannot be guaranteed, such as on a sports field, it is essential for the chiropractor to seek the patient's consent before proceeding with assessment or treatment.
The chiropractor should ensure that information contained on paper or electronically is kept secure and that access by non-authorised personnel is prevented
Confidentiality has exceptions, including situations where disclosure is mandated by law, when it serves the public interest, when there is a risk of death or serious harm to the patient or others, and when an official with the authority to order disclosure issues such an order.
Where disclosure takes place, the reasons for the disclosure should be recorded, as well as the nature and extent of the disclosure.
Discharging patients
The chiropractor should not treat the patient unnecessarily and should be able to clinically justify decisions to continue care
When care can no longer be justified on the basis of clinical need, the chiropractor should discharge the patient without delay
When discharging a patient, chiropractors must clearly communicate the reasons for ending care It is important not to discharge a patient solely due to their complaints or concerns about treatment However, in certain situations, such complaints may make the chiropractor-patient relationship unsustainable.
Chiropractors must provide patients with information on where to continue their care before discharging them, unless the treatment program has officially ended for clinical reasons This may include referrals to other healthcare professionals, potentially including another chiropractor Additionally, it is essential for chiropractors to document the rationale behind the patient's discharge.
Working with colleagues
General
Chiropractors must collaborate effectively within a team, valuing the skills and contributions of both fellow chiropractors and other health professionals involved in patient care Effective communication with colleagues, both within and outside the clinical team, is essential Additionally, chiropractors should offer support to colleagues facing challenges related to performance, conduct, or health.
Colleagues’ conduct and performance
Chiropractors must promptly address any concerns regarding the conduct, performance, or health of their colleagues to ensure patient safety In the absence of local reporting systems, these issues should be directed to the appropriate regulatory body If no regulatory body is available, concerns should be reported to the relevant national association.
Respect for colleagues
Chiropractors must treat their colleagues with fairness and respect, avoiding any unfair criticism or discrimination It is essential that they refrain from actions that could undermine patients' trust in their care or the judgment of their healthcare providers Additionally, chiropractors should ensure that their personal beliefs do not interfere with their professional relationships with colleagues.
Sharing information with colleagues
Effective patient care requires sharing relevant information with other health professionals When referring a patient, chiropractors must ensure that all pertinent details are communicated to the receiving health professional Additionally, it is essential to obtain the patient's consent before sharing this information.
Delegation and referral
When delegating responsibility, the chiropractor retains overall accountability for the patient's care It is essential for the chiropractor to verify that the individual receiving the delegated care has the appropriate qualifications, experience, knowledge, and skills Additionally, the delegating chiropractor must provide relevant information to support effective delegation.
Any person to whom a chiropractor makes a referral should be accountable to a regulatory body.
Honesty and trustworthiness
Chiropractors must uphold the trust placed in them by their patients and should never exploit this relationship Additionally, any chiropractor with a history of criminal convictions, cautions, or denial of membership in other professional organizations is obligated to disclose this information to their national association and relevant regulatory bodies.
Providing and publishing information about chiropractic services
Chiropractors must ensure that any promotional materials are honest, legal, and verifiable, avoiding any marketing tactics that could erode public trust in the profession They should refrain from making unjustifiable claims about treatment outcomes or guaranteeing cures Additionally, chiropractors should not pressure individuals into seeking services by instilling unfounded fears regarding their health It is also essential that they use professional titles accurately to prevent misleading the public about their qualifications.
Writing reports and giving evidence
Chiropractors must respond promptly and courteously to information requests from other health professionals and third parties, ensuring patient consent is obtained When providing evidence or statements, they should maintain honesty in all forms of testimony and acknowledge any limitations in their scope of practice In their reports, chiropractors should include all pertinent facts and restrict their opinions to areas within their expertise.
Research
Chiropractors engaged in research must prioritize the interests of participants, regardless of their patient status Research design should adhere to established scientific and ethical standards Honesty and integrity are essential in conducting research, ensuring that findings are accurately represented Compliance with the research protocol is crucial for both the chiropractor and their staff Additionally, maintaining the confidentiality of research subjects and obtaining informed consent at the beginning of any trial or experiment is imperative.
Financial dealings
Chiropractors must maintain transparency in their financial dealings with patients by clearly communicating fees and charges To prevent dependency, they should avoid using prepayment programs Additionally, chiropractors should not take advantage of a patient's lack of knowledge about chiropractic care when discussing costs They must refrain from encouraging patients to give gifts or money for personal benefit Lastly, honesty is essential when interacting with employers, insurers, and other relevant parties.
Conflicts of interest
Chiropractors must prioritize the best interests of their patients when making referrals and providing care, refraining from accepting any gifts or inducements that could influence their treatment decisions Additionally, they should avoid offering incentives to colleagues or other health professionals It is essential for chiropractors to transparently disclose any financial or commercial interests related to the products or services they recommend to patients.
Health and safety
General
Chiropractors must prioritize health and safety in their work environment by adhering to relevant legislation and managing associated risks They should establish contingency plans for emergencies involving patients or hazardous materials To mitigate infection risks, chiropractors need to implement systems that safeguard the health and wellbeing of patients, employees, and visitors Additionally, compliance with regulations regarding ionizing radiation is essential, and chiropractors should avoid techniques that necessitate the routine use of X-rays.
Evidence-based care
Chiropractic services must align with evidence-based care, ensuring that practitioners possess current knowledge in chiropractic research and the broader neuromusculoskeletal field Care should meet the standards of a competent chiropractor and be grounded in the best available evidence Additionally, clinical procedures should integrate recommendations from relevant national and international clinical guidelines in the neuromusculoskeletal area.
A-deviation: National deviation due to regulations, the alteration of which is for the time being outside the competence of the CEN/CENELEC member
This European Standard is not governed by any EC Directive In the applicable CEN/CENELEC countries, the A-deviations will remain in effect in place of the provisions of the European Standard until they are eliminated.
National Regulation Code de la santé publique art L 4130-1 2 (CSP) Code de la santé publique art L 4161-1 3 (CSP) Decree 2011-32 dated 7 January 2011 on chiropractic procedures and practising conditions 4 Law 2002-303 dated 4 March 2002 5 (ART 75)
2 http://www.legifrance.gouv.fr/affichCodeArticle.do?idArticle=LEGIARTI000020890163&cidTexte=LEGITEXT0000060726 65&dateTexte 130513&fastPos=1&fastReqId5215953&oldAction=rechCodeArticle
3 http://www.legifrance.gouv.fr/affichCodeArticle.do?idArticle=LEGIARTI000021709047&cidTexte=LEGITEXT0000060726 65&dateTexte 130513&oldAction=rechCodeArticle
4 http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000023387301
5http://www.legifrance.gouv.fr/affichTexte.do?cidTexte=JORFTEXT000000227015&fastPos=1&fastReqIdb5181647&cat egorieLien=cid&oldAction=rechTexte
Subclause 2.8 chiropractic health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health
Subclause 2.16 diagnostic procedure structured procedure that exists to enable a chiropractor to arrive at a diagnosis which may include physical examination, diagnostic imaging and laboratory tests
A chiropractor must gather and record both current and historical health information about a patient, encompassing physical, psychological, and social aspects of their wellbeing This is achieved by asking targeted questions to the patient, a responsible adult, or a legal guardian, with the goal of obtaining relevant clinical data that aids in diagnosing the patient and developing an effective care plan.
Subclause 3.1.4 Further investigation / diagnostic imaging
Chiropractors are responsible for identifying when additional investigations are necessary to prioritize the patient's best interests They should utilize further investigations that will enhance patient management and either conduct or interpret the results themselves, or refer the patient for appropriate assessments if needed Additionally, it is essential for chiropractors to document the outcomes of these investigations in the patient's record.
CSP L4130-1 designates medical practitioners, particularly general practitioners, as the primary healthcare professionals responsible for diagnosing, treating, and preventing disorders, as well as addressing their impact on overall health.
CSP L4161-1 specifies the cases of illegal practice of medicine (diagnosis, treatment): anybody who is not a physician medical practitioner cannot establish diagnosis and provide treatment (in writing, by oral examination)
Law 2002-303 art 75: Chiropractors have a title for a professional use, it is not a qualification for a healthcare profession
Therefore, French regulations clearly stipulate that practitioners merely holding a recognised chiropractor qualification cannot act in a medical capacity
According to Decree No 2011-32 Art 2, non-medical practitioners must refer patients to qualified physicians when symptoms necessitate medical diagnosis or treatment.
Therefore, in France the obligations of the Code de la Santé Publique and of the French Decree 2011-
32 shall be followed instead of the sections of
EN 16224 itemized in the left hand column of this table
Subclause 3.1.5 Clinical decision making and diagnosis
A chiropractor is responsible for evaluating a patient's health status and needs through case history, physical examination, and additional investigations They must formulate and document a working diagnosis or differential diagnosis, along with a rationale for care, which is continuously reviewed during the patient's treatment The chiropractor interprets all available information to make informed decisions regarding the patient's health and monitors changes over time Additionally, they consider the natural history and prognosis of any presenting complaints or emergencies, assessing the potential for preventing recurrences and managing long-term healthcare needs.
Subclause 3.2 Core competences b) The chiropractor shall have developed the following abilities:
1 ability to obtain appropriate consent before assessing individuals and for providing chiropractic care;
2 ability to take a comprehensive and problem- focused case history and perform an accurate physical examination;
3 ability to integrate case history, physical examination and diagnostic imaging to arrive at an appropriate diagnosis and/or differential diagnosis;
4 ability to interpret diagnostic procedures and make an appropriate response;
5 ability to select appropriate clinical skills and to formulate a management plan in concert with the patient;
6 ability to apply appropriate clinical skills in the treatment of a patient, and to provide information and advice for recovery and continued health;
7 ability to communicate clearly with patients, their families, other healthcare professionals, and the general public, and to ensure patients are fully informed of their treatment choices and care;
8 ability to interpret scientific evidence in a critical manner, and to find and use information relating to healthcare
[1] EN ISO 13485, Medical devices — Quality management systems — Requirements for regulatory purposes (ISO 13485)
[2] ISO 10001, Quality management — Customer satisfaction — Guidelines for codes of conduct for organizations
[3] ISO 10002, Quality management — Customer satisfaction — Guidelines for complaints handling in organizations
[4] ISO 29990, Learning services for non-formal education and training — Basic requirements for service providers
[5] prEN 15224:2011, Health care services — Quality management systems —Requirements based on
[6] CONSTITUTION OF THE WORLD HEALTH ORGANIZATION Available from: http://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf [viewed 2011-07-15]
[7] Council Directive 93/42/EEC of 14 June 1993, Article 17 Available from: http://eur- lex.europa.eu/LexUriServ/LexUriServ.do?uri=CONSLEG:1993L0042:20071011:en:PDF [viewed 2011- 07-15]
The Council Directive 96/29/Euratom, established on May 13, 1996, sets fundamental safety standards to protect the health of workers and the general public from the hazards associated with ionizing radiation.
Directive 95/46/EC, established by the European Parliament and Council on October 24, 1995, focuses on the protection of individuals concerning the processing of personal data and ensures the free movement of such data across member states This directive is crucial for safeguarding personal information and maintaining privacy rights within the European Union.
The European Council on Chiropractic Education (ECCE) outlines the accreditation procedures and standards for undergraduate chiropractic education and training in its 2011 version 4 document This resource is essential for ensuring quality in chiropractic education and is available for download on their official website.
[11] DICTIONARY W.F.C World Federation of Chiropractic, 2001 Available from: http://www.wfc.org/website/index.php?option=com_content&view=article&id&Itemid0&lang=en [viewed 2011-07-15]