Generic Client Consultation Form WHO Traditional Medicine Strategy 2014 – 2023 “Help health care leaders to develop solutions that contribute to a broader vision of improved health and patient autonomy.” Dr Margaret Chan Director –General of WHO Strategy: two key goals: 1. Support member states in harnessing the potential contribution of T&CM to health, wellness and people centered health care. 2. Promote the safe and effective use of T&CM through the regulation of products, practices and practitioners. Goals Attained by : Building the knowledge base and formulating national policies. Strengthening safety, quality and effectiveness through regulation. Promoting Universal health care coverage by integrating T&CM services and self – health care into national health systems. Frances Daly MSc. Vice -Chair FICTA 2015 - 2016

Executive summary WHO 1. Building the knowledge base – appropriate policies that understand and recognise the role and potential of T&CM 2. Strengthen Quality assurance – products, practices and practitioner's education, training skill development, services and therapies. Best practice approach through quality assurance and research. 3. Promoting universal health care Frances Daly MSc. Vice-Chair FICTA 2015 - 2016

SOPA Charting S Subjective O Objective A Assessment P Plan Frances Daly MSc. Vice -Chair FICTA 2015 - 2016

Generic Client records and consultation card SOAP Charting began in T&CM in 1984 to standardise the information required by therapist in order to treat clients. Insurance companies require chart notes to substantiate claims. Richard Aldler taught the first known SOAP charting method for therapists. It helped therapists of all therapies to be able to evaluate a client who may come to your clinic with their notes from another therapist. It standardises the clinic room information. This method would be in keeping with the WHO strategy 2014 -2023 Frances Daly MSc. Vice -Chair FICTA 2015 - 2016

Subjective Subjective information is: What the client tells you about themselves and current symptoms Personal information This includes the intake information on Page’s 1, 3, 4 Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Objective Objective information is: Your observations - Pages 5,6. Posture assessment /ROM / skin texture / hot / cold. Clients physical reactions to emotions. Clients Psycho- emotional reaction. Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Objective information Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Assessment This section may need to be modified for different therapies (i.e.subtle aromatherapy, Reiki, Reflexology and others). Here special tests specific to the therapy may be required (Sample page 7) CAM therapists combine the subjective and objective information gathered during the interview to form a consolidated treatment plan. Treatment Goals can be assessed in this section or when reviewing the treatment plan. Frances Daly MSc Vice -Chair FICTA 2015 - 2016

Treatment Plan The results and findings in the Subjective, Objective and Assessment stages are reviewed with the client (Page 8). Goals: both the short and long term goals of the client are reviewed. Goals of therapist both long and short term are discussed. A treatment plan is recommended by the therapist. When agreed by Client, Declaration of understanding (as per page 8) is signed by the Client before treatment begins Frances Daly MSc. Vice -Chair FICTA 2015 - 2016

Status report Report on the days treatment (Page 9) includes: How the client felt before, during and after treatment Therapists Objectives Therapists Strategy Modalities used Home Care advice Reflective practice Treatment goals this visit – achieved or not Therapist Signature Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

Narrative Reports consist of: A complete summary of the clients case from start to this day. Include initial Subjective , Objective, Assessment and Plan Then the progress to date highlighting major changes negative or positive Then list the clients present status Frances Daly Msc. Vice -Chair FICTA 2015 - 2016

FICTA research project WHO - quality assurance and research (Page 2) Family Medical history Name optional Male / Female DOB Therapy. Thanks to: Luminso Bioenergy healing Therapy - Sylvia Henrich; Oisin Bio-Energy healing Centre; Shen Therapy - Deirdre Leavy; Susan Gleeson-Walsh, Reiki; IISSM - Frances Daly; Lucy Mullee and Clive Lucas - ASK. Frances Daly Msc. Vice -Chair FICTA 2015 - 2016