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HEALTH ASSESSMENT INFORMATIONS - Are they really important?
by Mariette Troisfontaines

What is its use and its use is for whom?  Is it important to have one completed if you only see a client one time?   So many questions, reflections and time, so is it really worth it?  Nonetheless, this is requested in the ACTMD's code of ethics.  So let's take a closer look at these duties and obligations towards our clients:

Professional practice
The therapist is obliged to open a file containing the following informations for every new client and keep it up to date:
a) Names, sex, date of birth and client's address;
b) Consultation's date and time, client's condition as well as the client's history;
c) Description of applied health care;
d) The therapist's comments and observations concerning the evaluation and evolution of his client during the session.

I'm a hypnotherapist and I will share my personal experience in the advantages in completing the health assessment with my client instead of letting them fill it out alone in the waiting room.  I have conceived a version which permits me to come into contact with the client and have a better idea of his life history.  Like all health assessment sheets, I enter their name, sex, birth date, their address, their phone and/or cell phone number, their email address and I ask questions on any physical or mental health

Once the health assessment completed, the client feels that their health is taken care of and realizes that the professional works with a structure.  Several clients have confided that they were feeling better after have talked about their life, almost as if talking about their problems had a cartesian effect.  Some have affirmed that they felt listened and were treated as a human being.  A complete health assessment gives the professional a direction and clearer idea of the treatment to administer.  Listening and observing the client during this period gives me the occasion to better size-up the problems they are experiencing.

At the end of the treatment, I terminate my notes and I leave a resume on another sheet indicating only: the date, type of treatment, what functioned or not.  This enables me to find the more explicative sheet with the similar date.  Also, just a quick look on this resume sheet let's me do a quicker follow-up with any future appointments.

This may seem like allot of work, except, by doing so, I have far more easily gained my client's confidence in my professional expertise.  In completing the health assessment sheet and keeping it up to date, I can far more easily answer any questions the Insurance companies may ask on the treatments or bring any clarifications on the number of treatments. Obviously, by respecting the professional secret.  Or if ever I had to deal with a pursuit, I have everything in the file: the date, type of treatments, the reactions, the results, the client's evolution which justifies and explains the sense of the treatment sequence.

So, what is its use and its use is for whom?  It serves for efficient and structural professionalism, and serves as a point of reference for the health care.

Is it important to have one completed if you only see a client one time?   This is true even if we have a client only once, we have a better idea what to do and how to go about the treatment.  We always need to know if there are any contraindications for the treatment.  And we never know when a client would come back to see us.

And now it is my turn to ask the million dollar question: a health assessment was it really worth it?  

Mariette Troisfontaines  hypnotherapist





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