General principles for BSCN guidelines
These documents seek to make recommendations that are:
- evidence based
- relevant to the current and future working practices of a specialty
- in a form that is auditable
These recommendations are not intended for use in unselected patients where a clinical differential diagnosis exists: for these patients a medically qualified practitioner has to take a history and examine the patient before deciding the most appropriate investigation protocol to perform. Although the recommendations are of necessity prescriptive, they do not exclude protocols created for use in any individual department depending on local practice and resources. Despite this, if there is a deviation from a standard, the reasons should be documented.
A number of basic statements that underpin these recommendations:
- Clinical Neurophysiology is a branch of Clinical Medicine. Thus, whether investigations are carried out by or under the supervision of Consultant Clinical Neurophysiologists (CCN) or by suitably qualified Clinical Physiologists (Neurophysiology) (CP), the same duty of patient care applies.
- Clinical Neurophysiological procedures and reports should only be carried out by medical and physiological staff who have undertaken the necessary training and having received due recognition as competent by their relevant professional body following competence-based assessments.
- Neurophysiological assessments should always be carried out in safe circumstances, and therefore where possible the presence of medical staff within the department where tests are carried out is desirable both for medical emergencies and for supervision.
- The Neurophysiological Investigation is only part of the process that begins with a referral. The referrer must always understand what information they are being provided with and by whom. Thus a report based only on technical data and not clinical opinion must be identified as such and qualified in terms such as in Appendix a. At no time should a technical opinion only be couched in terms that indicate a clinical diagnosis, if the appropriate clinical correlation has not been made by an appropriately trained practitioner.
- Practitioners whether medical or otherwise remain responsible for the reports they sign. Thus, if a report is signed by a Consultant as a Medical Clinical Neurophysiological opinion, this is what it must be. The practice of semi-automatic countersignature of reports about investigations of which the signer knows little must be considered inappropriate.
- The medico legal responsibility for the investigation is explicitly with the person signing the report. Such practitioners need to seek confirmation of their indemnity insurance status from their employers.
- Referrals to Clinical Neurophysiology come from many sources, and many grades and competencies of medical and paramedical staff. Thus clinic selection decisions based only on referral information should be limited and taken with caution.
- Data collection and storage will vary for different departments and equipment. An aspirational aim should be that all original data should be stored electronically, available for review at the time of reporting, and archived (with appropriate backup).
- “The freedom of conscience clause”. Any document that proposes guidelines is open to misinterpretation. The principles of clinical autonomy must allow practitioners to practice in the way best appropriate to their local context, training and professional opinion They must however be prepared to defend the statement that their practice would be such that a body of their peers would deem it competent, particularly is standards are not adhered to.
In tests where a medical clinical opinion is not available, one of the following qualifying statements on the report is recommended (No. 1 preferred):
- The opinion is based solely on the objective electrophysiological data and must be taken in the context of the clinical situation known to the referring doctor.
- This patient has been examined by a specially trained Clinical Physiologist (Neurophysiology). The opinion is based on a limited clinical questionnaire and the objective electrophysiological data. The opinion should be placed in the full clinical context by the referring doctor.
Common standards for neurophysiological testing
The following Standards apply to all neurophysiological testing/reporting:
1) Before starting testing the patient is identified and the clinical information from the referral verified
2) The report of the investigation contains any applicable numerical data
3) The report makes a statement on any abnormality detected
4) The professional status of the practitioners performing the investigation and providing the report are stated
5) The report is signed by the practitioner taking medico-legal responsibility for it