Code of conduct

This code is substantially based on the Code of conduct for registered health practitioners adopted by a number of the National Boards as part of the National Registration and Accreditation Scheme (the National Scheme) with further inclusions specifically for the chiropractic profession.

This code seeks to assist and support chiropractors to deliver safe and effective health services within an ethical framework. All health practitioners have a duty to make the care of patients their first concern and to practise safely and effectively. Maintaining a high level of professional competence and conduct is essential for providing good care.

This code is a guide to the expected standards of behaviour of chiropractors in relation to:

• providing good care, including shared decision-making
• working with patients
• working with other practitioners
• working within the healthcare system
• minimising risk
• maintaining professional performance
• professional behaviour and ethical conduct
• ensuring health practitioners’ health
• teaching, supervising and assessing
• public health activities
• research
• radiology and radiography, and
• duration and frequency of care.

Making decisions about healthcare is the shared responsibility of the health practitioner and the patient (or their representative).

Practitioners must practise in an evidence-based and patient-centred manner so that they provide the best possible healthcare for their patients.

An important part of the health practitioner–patient relationship is effective communication. Relationships based on openness, trust and good communication (in person, written and electronic) will enable health practitioners to work in partnership with their patients.

Health practitioners have ethical and legal obligations to protect the privacy of people requiring and receiving care. Patients have a right to expect that health practitioners and their staff will hold information about them in confidence, unless information is required to be released by law or due to public interest considerations.

Health practitioners need to obtain informed consent for the care that they provide to their patients. Caring for children and young people brings additional responsibilities for health practitioners.
Good practice involves genuine efforts to understand the cultural needs and contexts of different patients to obtain good health outcomes. Health practitioners need to be aware that some patients have additional needs and modify their approach appropriately.

When adverse events occur, health practitioners have a responsibility to be open and honest in communication with patients and in reviewing what happened.

In some circumstances, the relationship between a health practitioner and a patient may become ineffective or compromised, and may need to end.

Good relationships with colleagues and other health practitioners strengthen the health practitioner– patient relationship and enhance care.

Health practitioners have a responsibility to contribute to the effectiveness and efficacy of the healthcare system.

Minimising risk to patients is a fundamental component of practice. Good practice involves understanding and applying the key principles of risk minimisation and management to practice.

Health practitioners maintaining and developing their knowledge, skills and professional behaviour are core aspects of good practice.

Teaching, supervising and mentoring health practitioners and students is important for their development and for the care of patients. It is part of good practice to contribute to these activities, and provide support, assessment, feedback and supervision for colleagues, health practitioners-in-training and students.

1.1 Use of this code

The Code of conduct for chiropractors seeks to assist and support chiropractors to deliver appropriate, safe and effective services within an ethical framework. Chiropractors have a professional responsibility to be familiar with this code and to apply the guidance it contains.

This code should be read and considered as an entire document and as a document that integrates a number of other codes and standards. Chiropractors need to be aware of, and comply with all standards, guidelines and policies of the Chiropractic Board of Australia (the National Board).¹

This code will be used:

1. to support individual chiropractors in the task of providing good healthcare and fulfilling their professional roles and to provide a framework to guide professional judgement
2. to assist the National Board in its role of protecting the public by setting and maintaining expectations of good practice
3. to assist the National Board in evaluating the ethical and professional conduct as well as the performance of practitioners – if ethical, professional conduct or performance varies significantly from this code, chiropractors will be held accountable to explain and justify their decisions and actions, and failure to meet this code may have consequences for registration
4. as an additional resource for a range of uses that contribute to enhancing the culture of professionalism in the Australian health system: for example, in chiropractic education; orientation, induction and supervision of students; and by administrators and policy makers, and
5. as a guide for the public and consumers of health services about the standards of ethical and professional conduct and professional performance they should expect from registered chiropractors.

Chiropractors must always act in accordance with the law. The code is not a substitute for the provisions of the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law), other relevant legislation and case law. If there is any conflict between the code and the National Law, the law takes precedence.

Chiropractors are subject to a range of general legal obligations and specific obligations under legislation, for example, privacy, child protection and health records. Chiropractors should ensure that they are aware of these obligations and act in accordance with them.

The practice of chiropractic is challenging and rewarding. No code or guidelines can ever encompass every situation or replace the insight and professional judgement of chiropractors. Good practice means using this judgement to try to practise in a way that would meet the standards expected of you by your peers and the community.

While good healthcare respects the rights of patients, this code is not a charter of rights. Health practitioners have critical roles in caring for people who are unwell, assisting people to recover and seeking to ensure people stay well.

This code outlines the National Board’s expectations in relation to the professional and ethical conduct of registered chiropractors but it is not an exhaustive study of professional ethics or an ethics guide. It does not address the clinical practice of the profession. The focus of this code is on good practice and professional behaviour. It is not intended as a mechanism to address disputes between professional colleagues in relation to termination of business relationships and disputes over clients.

Chiropractors should acknowledge and comply with supplementary guidance published by the National Board from time to time on specific issues.

¹These can be found on the National Board’s website and as appendixes to this code.

1.2 Professional values and qualities

While individual health practitioners have their own personal beliefs and values, there are certain professional values on which all health practitioners are expected to base their practice. These professional values apply to the practitioners conduct regardless of the setting, including in person and electronically, e.g. in the social media.

Health practitioners have a duty to make the care of patients their first concern and to practise safely and effectively.

Health practitioners must be ethical and trustworthy. Patients trust health practitioners because they believe that, in addition to being competent, health practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion. Patients also rely on health practitioners to protect their confidentiality.

Health practitioners have a responsibility to protect and promote the health of individuals and the community.

Good practice is centred on patients. It involves health practitioners understanding that each patient is unique and working in partnership with patients, adapting what they do to address the needs and reasonable expectations of each person. This includes cultural awareness: being aware of their own culture and beliefs, and respectful of the beliefs and cultures of others, and recognising that these cultural differences may affect the health practitioner–patient relationship and on the delivery of services. It also includes being aware that differences such as gender, sexuality, age, belief systems and other anti-discrimination grounds may influence care needs and avoiding discrimination on the basis of these differences.

Effective communication in all forms underpins every aspect of good practice.

Professionalism embodies all the qualities described here and includes self-awareness and self-reflection. Health practitioners are expected to reflect regularly on whether they are practising effectively, on what is happening in their relationships with patients and colleagues, and on their own health and wellbeing. They have a duty to keep their skills and knowledge up to date, refine and develop their clinical judgement as they gain experience, and contribute to their profession.

All practitioners have a responsibility to recognise and work within the limits of their competence, scope and areas of practice. Areas of practice vary according to different roles; for example, health practitioners, education providers, researchers and managers will all have quite different competencies and scopes of practice.

Health practitioners should be committed to safety and quality in healthcare.²

²See the Australian Commission on Safety and Quality in Health Care.

1.3 Australia and Australian healthcare

Australia is culturally and linguistically diverse. Health practitioners in Australia reflect the cultural diversity and this enhances our healthcare system and strengthens the health profession.

There are many ways to practice a health profession in Australia. Practitioners have critical roles in caring for people who are unwell, assisting people to recover and seeking to keep people well. This code focuses on these roles. For practitioners with roles that involve little or no contact with patients, not all of this code may be relevant, but the underpinning principles will still apply.

1.4 Substitute decision-makers

There are several conditions or situations in which patients may have limited competence or capacity to make independent decisions about their healthcare; for example, people with dementia or acute conditions that temporarily affect competence, and children or young people, depending on their age and capacity (see Section 3.5 Informed consent).

In this code, reference to the term ‘patients’ also includes substitute decision-makers for patients who do not have the capacity to make their own decisions. These can be parents or a legally appointed decision-maker. If in doubt, seek advice from the relevant guardianship authority.

2.1 Introduction

The practice of any health profession has both clinical and non-clinical aspects. Certain levels of professional values and behaviours are required of all chiropractors regardless of their practice. For those in clinical practice, providing good care to patients is their primary concern.

Providing good care includes:

1. appropriately assessing the patient, taking into account their history (history includes relevant psychological, social and cultural aspects), views and conducting an appropriate physical examination
2. ensuring that the diagnosis/clinical impression is appropriate, relevant, justifiable and based on sound clinical reasoning
3. identifying ‘red flags’ and investigating, managing, co-managing or referring as appropriate
4. formulating and implementing a reasonable management plan (including providing treatment/care and advice and, where relevant, arranging investigations and liaising with other treating practitioners)
5. the need to monitor and review care
6. facilitating coordination and continuity of care, and
7. recognising and respecting the rights of patients to make their own decisions.

2.2 Good practice

Maintaining a high level of professional competence and conduct is essential for the good practice of the profession. Good practice involves:

1. recognising and working within the limits of the chiropractor’s competence and scope and area of practice, which may change over time
2. maintaining adequate knowledge and skills to provide safe and effective care, including providing treatment/care and advice and where relevant, arranging investigations and liaising with, or referring to, other health professionals
3. practising patient-centred care, including encouraging patients to take interest in, and responsibility for, the management of their health and supporting them in this
4. maintaining adequate records (see Section 9.4 Health records)
5. considering the balance of benefit and harm in all clinical management decisions
6. communicating effectively with patients (see Section 3.3 Effective communication)
7. providing treatment/care options based on the best available information and practising in an evidence-based context and not being influenced by financial gain or incentives
8. ensuring that services offered are provided with the best possible skill, care and competence
9. taking steps to alleviate the symptoms and distress of patients
10. supporting the right of the patient to seek a second opinion
11. consulting with and taking advice from colleagues when appropriate
12. making responsible and effective use of the resources available to chiropractors (see Section 6.2 Wise use of healthcare resources)
13. ensuring that the chiropractor’s personal views do not adversely affect the care of their patients, and
14. evaluating practice and the decisions made and action taken in providing good care.

2.3 Shared decision-making

Making decisions about healthcare is the shared responsibility of the chiropractor and the patient. Patients may wish to involve their family, carer or others. (See Section 1.4 Substitute decision-makers).

2.4 Decisions about access to care

A chiropractor’s decision about access to care needs to be free from bias and discrimination.

Good practice involves:

1. treating patients with respect at all times
2. not prejudicing the care of a patient because the chiropractor believes that the behaviour of the patient has contributed to their condition
3. upholding the duty of care to the patient and not discriminating on grounds irrelevant to healthcare, including age, race, religion, sex, disability or other grounds specified in anti-discrimination legislation
4. investigating and treating patients on the basis of clinical need and the effectiveness of the proposed investigations or treatment/care, providing necessary services and not providing unnecessary services or encouraging the indiscriminate or unnecessary use of health services
5. keeping chiropractors and their staff safe when caring for patients; appropriate action should be taken to protect chiropractors and their staff if a patient poses any risk to health or safety. The patient should not be denied care if reasonable steps can be taken to keep chiropractors and their staff safe
6. being aware of the chiropractor’s right to not provide or participate directly in treatment/care to which that chiropractor conscientiously objects; informing patients and, if relevant, colleagues, of the objection, and not using that objection to impede access to treatment/care that is legal
7. not allowing moral or religious views to deny patients access to healthcare, recognising that chiropractors are free to decline to provide or participate in that care personally, and
8. when care is declined, making appropriate referral.

2.5 Treatment/care in emergencies

Treating patients in emergencies (whether within practice or in a first aid situation) requires chiropractors to consider a range of issues in addition to the provision of best care. Good practice involves offering assistance in an emergency that takes account of the chiropractor’s own safety, skills, the availability of other options and the impact on any other patients under the chiropractor’s care, and continuing to provide that assistance until services are no longer required.

3.1 Introduction

Relationships based on respect, trust and good communication will enable chiropractors to work in partnership with patients.

3.2 Partnership

A good partnership between a chiropractor and the person they are caring for requires high standards of personal conduct. This involves the chiropractor:

1. being courteous, respectful, compassionate and honest
2. treating each patient as an individual
3. protecting the privacy and right to confidentiality of patients, unless release of information is required by law or due to public interest considerations
4. encouraging and supporting patients and, when relevant, their carer/s or family in caring for themselves and managing their health
5. encouraging and supporting patients to be well-informed about their health and assisting patients to make informed decisions about their healthcare activities and treatment/care by providing information and advice to the best of the chiropractor’s ability and according to the stated needs of the patient
6. respecting the right of the patient to choose whether or not they participate in any treatment/care or acts on advice, and
7. recognising that there is a power imbalance in the chiropractor-patient relationship. It is important to ensure that all decisions are directly relevant to clinical experience; unaffected by non-clinical motivations; and capable of being regarded so by reasonable observers in the circumstances (also see Section 9.2 Professional boundaries and Section 9.12 Financial and commercial dealings).

A good partnership between the chiropractor and the person they are caring for also involves the patient contributing to the effective therapeutic partnership by:

1. working cooperatively, and in partnership with the chiropractor
2. communicating effectively and with sincere intent
3. being fair and accurate in providing feedback, and
4. ensuring that any complaints are honest and reasonable in the circumstances.

3.3 Effective communication

An important part of the chiropractor–patient relationship is effective communication. This involves

1. listening to patients, asking for and respecting their views about their health and responding to their concerns and preferences
2. awareness of health literacy issues and taking the health literacy of a patient into account and adjusting their communication accordingly
3. encouraging patients to tell the chiropractor about their condition and how it has been managed including any other health advice they have received, any prescription or other medications they have been prescribed and any other therapies they are using
4. informing patients of the nature and relevance of all aspects of their clinical care, including examination and investigations, giving them adequate opportunity to question or refuse interventions and treatment/care
5. discussing with patients their condition and other available healthcare options, including their nature, purpose, possible positive and adverse consequences and limitations and reasonable alternatives wherever they exist
6. endeavouring to confirm that a patient understands what the chiropractor has said
7. ensuring that patients are informed of the material risks associated with any part of a proposed management plan
8. responding to questions from patients and keeping them informed about their clinical progress
9. making sure, wherever practical, that arrangements are made to meet the specific language, cultural and communication needs of patients and being aware of how these needs affect understanding
10. becoming familiar with, and using wherever necessary, appropriately qualified people to help meet the communication needs of patients, including those who require assistance because of their language skills, mental health, or because they are speech, hearing or sight impaired (in such cases practitioners should use trained translators and interpreters rather than family members or staff wherever possible)
11. obtaining consent from the patient to use a person to interpret
12. using social media, e-health and personally controlled electronic health records appropriately, and
13. communicating appropriately with, and providing relevant information to, other stakeholders including members of the treating team where necessary and appropriate, in accordance with applicable privacy requirements.

3.4 Confidentiality and privacy

Chiropractors have ethical and legal obligations to protect the privacy of people requiring and receiving care. Patients have a right to expect that chiropractors and their staff will hold information about them in confidence, unless release of information is required by law or public interest considerations. Good practice involves:

1. treating information about patients as confidential and applying appropriate security to electronic and hard copy information
2. seeking consent from patients before disclosing or sharing information
3. being aware of the requirements of the privacy and/or health records legislation (and common law) that operates in relevant states and territories and complying with these requirements to provide information held in all formats, including electronic information
4. sharing information appropriately about patients’ health care while remaining compliant with privacy legislation and professional guidelines about confidentiality
5. providing appropriate surroundings to enable private and confidential consultations and discussions to take place where necessary, to the exclusion of all other people
6. ensuring that a patient’s confidentiality, privacy and standards of care are maintained even in a practice setting where there is limited aural and visual privacy
7. ensuring that all staff are aware of the need to respect the confidentiality and privacy of patients and refrain from discussing patients in a non-professional context
8. complying with relevant legislation, policies and procedures relating to consent
9. using appropriate consent forms for release of information which limits disclosure to relevant health and medical information, and
10. ensuring that use of social media and e-health is consistent with the practitioner’s ethical and legal obligations to protect privacy.

3.5 Informed consent

Informed consent is a person’s voluntary decision about healthcare that is made with knowledge and understanding of the benefits and risks involved. A useful guide to the information that chiropractors need to give to patients is available in the National Health and Medical Research Council (NHMRC) publication General guidelines for medical practitioners in providing information to patients.³

The NHMRC guidelines cover the information that chiropractors should provide about their proposed management or approach, including the need to provide more information where the risk of harm is greater and likely to be more serious, and advice about how to present information. Good practice involves:

1. providing information to patients in a way they can understand before asking for their consent
2. providing an explanation of the treatment/care recommended, its likely duration, expected benefits and cost, any alternative(s) to the proposed care, their relative risks/benefits, as well as the likely consequences of no care
3. obtaining informed consent or other valid authority before undertaking any examination or investigation, providing treatment/care (this may not be possible in an emergency) or involving patients in teaching or research, including providing information on material risks
4. consent being freely given, without coercion or pressure
5. advising patients, when referring a patient for investigation or treatment/ care, that there may be additional costs, which they may wish to clarify before proceeding
6. obtaining (when working with a patient whose capacity to give consent is or may be impaired or limited) the consent of people with legal authority to act on behalf of the patient, and attempting to obtain the consent of the patient as far as practically possible
7. being mindful of additional informed consent requirements when supplying or prescribing products not approved or made in Australia, and
8. documenting consent appropriately, including considering the need for written consent for procedures that may result in serious injury or death.

³Available on the NHMRC website under Guidelines.

3.6 Informed financial consent

Informed consent about healthcare also includes informed consent about financial matters.
Good practice involves a discussion about fees in a manner appropriate to the relationship and should include discussion about the cost of all required services and a general agreement as to the level of treatment/care to be provided.

When choosing to use financial agreements, good practice involves:

1. ensuring that any financial agreement is based on the clinical needs of the patient
2. ensuring that the patient clearly understands the nature of all of the terms and conditions of the agreement
3. ensuring that the agreement includes full written disclosure of all of the terms and conditions
4. providing a reasonable ‘cooling-off’ period in accordance with applicable Australian consumer law and the circumstances of the patient
5. offering a ‘pay-as-you-go’ alternative
6. ensuring the agreement includes a reasonable refund policy, which includes no financial disadvantage for early termination of the agreement
7. ensuring the amount, time and quality of care delivered does not differ between those patients (with similar conditions) on a pre-paid financial agreement, and those who are not
8. ensuring the agreement is reviewed every three months or 12 visits, whichever is the greatest, and
9. ensuring agreements do not extend beyond three months or 12 visits, whichever is the greatest, unless there is clear and appropriate clinical justification to support a renewed period of agreement and care.

3.7 Children and young people

Caring for children and young people brings additional responsibilities for chiropractors. Mandatory reporting of child abuse and neglect is legislated in all states and territories in Australia. Practitioners have a responsibility to be aware of, and comply with, any mandatory reporting requirements in their state or territory. This section should be read in close conjunction with Sections 2.1 and 2.2: Good practice.

Good practice with children and young people involves:

1. recognising that children have their own special needs and considerations
2. placing the interests and wellbeing of the child or young person first
3. identifying ‘red flags’ particular to children and young people and investigating, managing, co-managing or referring as appropriate
4. ensuring informed consent to providing care for children involves the patient’s parent and/or guardian being provided with clinically relevant information for the chiropractic management of the child; unless a chiropractor judges that a child is of sufficient age and mental and emotional capacity to give their own consent to a service and relevant state and territory laws are complied with
5. ensuring that risks of care and alternatives to care are sufficiently explained as these are essential elements of informed consent (see Section 3.5 Informed consent)
6. ensuring that, when communicating with a child or young person, chiropractors:
   • treat the child or young person with respect and listen to their views
   • encourage questions and answer those questions to the best of their ability
   • provide information in a way the child or young person can understand
   • recognise the role of parents and/or guardians and, when appropriate, encourage the child or young person to involve their parents and/or guardians in decisions about care, and
   • remain alert to children and young people who may be at risk and notify appropriate child protection authorities as required by law.
7. ensuring that x-rays of children are obtained only where there are clinical indications for the procedure (see also Appendix 2: Guideline in relation to radiology/radiography), and
8. ensuring compliance with the special requirements relating to record keeping for minors and children that are set out in relevant state and territory legislation.

3.8 Culturally safe and sensitive practice

Awareness of the cultural diversity that exists and how this affects the delivery of healthcare is an important consideration for health practitioners. Good practice involves genuine efforts to understand the cultural needs and contexts of different patients to obtain good health outcomes. This includes:

1. having knowledge of, respect for and sensitivity towards the cultural needs and background of the community practitioners serve, including those of Aboriginal and/or Torres Strait Islander Australians and those from culturally and linguistically diverse backgrounds. For example, cultural issues may mean a patient needs to be consulted or treated by a practitioner of the same gender, resulting in better and safer outcomes
2. acknowledging the social, economic, cultural and behavioural factors influencing health, both at individual and population level
3. understanding that a chiropractor’s own culture and beliefs influence their interactions with patients, and
4. adapting practice to improve engagement with patients and healthcare outcomes.

3.9 Patients with additional needs

Some patients (including those with impaired decision-making capacity) have additional needs. Good practice in managing the care of these patients includes:

1. paying particular attention to communication
2. being aware that increased advocacy by a practitioner may be necessary to ensure a patient’s fair access to healthcare
3. recognising that there may be a range of people involved in their care such as carers, family members or a guardian, and involving them when appropriate, and
4. being aware that these patients may be more vulnerable.

3.10 Relatives, carers and partners

Good practice involves:

1. being considerate to relatives, carers, partners and others close to the patient, and respectful of their role in the care of the patient, and
2. with appropriate consent, being responsive in providing information.

3.11 Adverse events and open disclosure

When adverse events occur, chiropractors have a responsibility to be open and honest in communication with the patient and in reviewing what happened and reporting appropriately (also see Section 7.2(a)). When something goes wrong, good practice involves:

1. recognising what has happened
2. acting immediately to rectify the problem, if possible, including seeking any necessary help and advice
3. explaining to the patient as promptly and fully as possible what has happened and the anticipated short-term and long-term consequences
4. listening to the patient or client
5. acknowledging any patient distress and providing appropriate support
6. providing an expression of regret as soon as possible in accordance with ‘open disclosure’ good practice
7. complying with any relevant policies, procedures and reporting requirements, subject to advice from a professional indemnity insurer
8. reviewing adverse events and implementing changes to reduce the risk of recurrence (see Section 7 Minimising risk)
9. reporting adverse events to the relevant authority as required (see Section 7 Minimising risk), and
10. ensuring patients have access to information about the process for making a complaint (for example, through the relevant board or healthcare complaints commission).

3.12 When a complaint is made by a patient

Patients who are not satisfied have a right to complain about their care. When a complaint is made, or a formal notification is received by the National Board, good practice involves:

1. acknowledging the person’s right to complain
2. working with the person to resolve the issue where possible
3. providing a prompt, open and constructive response, including an explanation and, if appropriate, an apology or expression of regret
4. ensuring the complaint/notification does not adversely affect the person’s care; in some cases, it may be advisable to refer the person to another practitioner, and
5. complying with the requirements of any relevant complaints legislation (including the notification provisions of the National Law).

3.13 End-of-life care

Practitioners have a vital role in assisting the community to deal with the reality of death and its consequences. In caring for patients or clients towards the end of their life, good practice involves:

1. taking steps to manage a person’s symptoms and concerns in a manner consistent with their values and wishes
2. where relevant, providing or arranging appropriate palliative care
3. understanding the limits of services in prolonging life and recognising when efforts to prolong life may not benefit the person
4. for those practitioners involved in care that may prolong life, understanding that practitioners do not have a duty to try to prolong life at all cost but do have a duty to know when not to initiate and when to cease attempts at prolonging life, while ensuring that patients or clients receive appropriate relief from distress
5. accepting that patients or clients have the right to refuse treatment or to request the withdrawal of treatment already started
6. respecting different cultural practices related to death and dying
7. striving to communicate effectively with patients or clients and their families so they are able to understand the outcomes that can and cannot be achieved
8. where relevant, facilitating advanced care planning
9. taking reasonable steps to ensure that support is provided to patients or clients and their families, even when it is not possible to deliver the outcome they desire
10. communicating with patients or clients and their families about bad news or unexpected outcomes in the most appropriate way and providing support for them while they deal with this information, and
11. when a patient or client dies, being willing to explain, to the best of the practitioner’s knowledge, the circumstances of the death to appropriate members of their family and carers, unless it is known the patient or client would have objected.

3.14 Ending a professional relationship

In some circumstances, the relationship between the chiropractor and a patient may become ineffective or compromised, and may need to end. Good practice involves ensuring that the patient is adequately informed of the decision and facilitating arrangements for the continuing care of the patient, including passing on relevant clinical information.

3.15 Personal relationships

Good practice includes chiropractors recognising the potential conflicts, risks and complexities of providing care to those with whom they have a close relationship, e.g. close friends, work colleagues and family members. In some cases, this can be inappropriate because of a lack of objectivity, possible discontinuity of care and risks to the practitioner or patient. When a practitioner chooses to provide care to those in a close relationship, good practice requires that:

1. the conflict of interest is acknowledged and declared
2. adequate records are kept
3. confidentiality is maintained
4. adequate assessment occurs
5. appropriate consent is obtained for the circumstances which is acknowledged by both the chiropractor and patient
6. the personal relationship does not in any way impair clinical judgement, and
7. an option to discontinue care is maintained at all times.

3.16 Working with multiple patients

Where chiropractors are considering treating multiple patients simultaneously in class or group work, or more than one individual patient at the same time, they should consider whether this mode of treatment/care is appropriate for the patients involved.

Chiropractors should be especially conscious of the privacy and confidentiality of their patients in such environments (see also Section 3.4 Confidentiality and privacy).

3.17 Closing or relocating a practice

When closing or relocating a practice, good practice involves:

1. giving advance notice where possible, and as early as possible, and
2. facilitating arrangements for the continuing care of all current patients, which may include the transfer or appropriate management of all patient records in accordance with the legislation governing privacy and health records in the jurisdiction.

4.1 Use of diagnostic and therapeutic modalities in chiropractic practice

Chiropractors use varying diagnostic and therapeutic tools, tests and procedures in the assessment and management of patients. Ensuring a high level of competence and skill in using particular diagnostic or therapeutic modalities is essential to good care.

Chiropractors should ensure that they are appropriately trained, skilled and qualified to practise any modalities used. In addition, chiropractors should be aware of any relevant local, state or territory laws that may affect the practice of different modalities.

Good practice involves:

1. a full and thorough assessment of patients using tools, tests and procedures that are appropriate for the gathering of information necessary to form a reasonable diagnosis or clinical impression
2. understanding the validity and reliability of any modality used and appropriate incorporation into their clinical regime
3. only using diagnostic tools, tests and procedures in accordance with established protocols for their appropriate use (see also Appendix 2: Guideline in relation to radiology/radiography)
4. evaluating and reporting the data obtained in a contextual way to ensure that a reasonable and relevant diagnosis/clinical impression is formed, and that appropriate and necessary care is provided
5. when using tools, tests and procedures in formulating a diagnosis/clinical impression, management plan and/or for prognostic purposes, the tools used should be for conditions where there are demonstrated acceptable levels of reliability and validity, and
6. not misrepresenting the clinical value or significance of the findings of any tool, test or procedure.

5.1 Respect for colleagues and other practitioners

Good care is enhanced when there is mutual respect and clear communication between all health professionals. Good practice involves:

1. communicating clearly, effectively, respectfully and promptly with colleagues and other practitioners on professional matters
2. acknowledging and respecting the contribution of all practitioners involved in patient care, and
3. behaving professionally and courteously to colleagues and other practitioners at all times, including when using social media.

5.2 Delegation, referral and handover

Delegation involves a chiropractor asking another person or member of staff to provide care on behalf of the delegating chiropractor while that chiropractor retains overall responsibility for the care of the patient.

Referral involves a chiropractor sending a patient to obtain an opinion or treatment/care from another practitioner. Referral usually involves the transfer (in part) of responsibility for the care of the patient, usually for a defined time and a particular purpose, such as care that is outside the referring chiropractor’s expertise or scope of practice.

Handover is the process of transferring all responsibility to another practitioner.

Good practice involves:

1. taking reasonable steps to ensure that the person to whom the chiropractor delegates, refers or hands over has the qualifications and competence to provide the care required
2. understanding that, although the delegating chiropractor will not be accountable for the decisions and actions of those to whom they delegate, the delegating chiropractor remains responsible for the overall management of the patient and for the decision to delegate, and
3. always communicating sufficient information about the patient and the treatment/care needed to enable the continuing care of the patient.

5.3 Working with other practitioners

Many chiropractors work closely with a wide range of other practitioners, with benefits for patient care. Effective collaboration is a fundamental aspect of good practice when working with other practitioners.
The care of patients is improved when there is mutual respect and clear communication, as well as an understanding of the responsibilities, capacities, constraints and ethical codes of each other’s health professions.

Working with other practitioners does not alter a chiropractor’s personal accountability for professional conduct and the care provided. Good practice involves:

1. understanding the particular role of each practitioner and attending to the responsibilities associated with their own role
2. advocating for a clear delineation of roles and responsibilities, including that there may be a recognised team leader or coordinator, although care within the team may be provided by different practitioners from different health professions within different models of care
3. communicating effectively with other practitioners
4. informing patients about the roles of other practitioners
5. acting as a positive role model for other practitioners
6. understanding the nature and consequences of bullying and harassment, and seeking to avoid or eliminate such behaviour between all treating practitioners, and
7. supporting students and practitioners receiving supervision.

5.4 Delegation to unregistered staff, chiropractic students and assistants

It may be necessary at times in practice to delegate some clinical activities to staff, students or assistants. When delegating clinical activities, chiropractors have a responsibility to ensure that the person to whom they are delegating can safely and competently perform the delegated activity. When delegating clinical activities to staff, chiropractic students (not undertaking a supervised external clinical placement), assistants or other people, good practice involves:

1. only delegating activities that do not require the unique skill, knowledge, discretion and judgment of a chiropractor
2. ensuring that the delegate has adequate skills, training, expertise or proficiency in the activity
3. ensuring that the delegate fully understands what is expected of them in performing the activity
4. obtaining specific consent from the patient for a delegate to perform the activity, and
5. recognising that the chiropractor who delegates an activity to another person is accountable, not only for their decision to delegate, but also for monitoring and reviewing the delegate’s standard of performance.

Note: Section 5.4 does not apply to registered chiropractic students undertaking a supervised external clinical placement as a part of a National Board-approved program of study.

6.1 Introduction

Chiropractors have a responsibility to contribute to the effectiveness and efficiency of the healthcare system.

6.2 Wise use of healthcare resources

It is important to use healthcare resources wisely. Good practice involves:

1. ensuring that the services provided are appropriate for the assessed needs of the patient and are reasonably required, necessary and not excessive, upholding the right of patients to gain access to the necessary level of healthcare, and, whenever possible, helping them to do so
2. supporting the transparent and equitable allocation of healthcare resources, and
3. understanding that the use of resources can affect the access other patients have to healthcare resources.

6.3 Health advocacy

There are significant disparities in the health status of different groups in the Australian community. These disparities result from social, cultural, geographic, health-related and other factors. Good practice involves using expertise and influence to protect and advance the health and wellbeing of individual patients, communities and populations.

6.4 Public health matters

Chiropractors have a responsibility to promote the health of the community through disease prevention and control, education and, where relevant, screening.

On any public health matter, practitioners are obliged to provide balanced, unbiased and evidence-based information in order to enable members of the public to make informed health decisions. When called upon to provide advice that is beyond their usual area of practice, chiropractors should seek to refer those patients to another practitioner who possess such expertise.

Good practice involves:

1. understanding the principles of public health, including health education, health promotion, disease prevention, and control and screening
2. participating in efforts to promote the health of the community and being aware of obligations in disease prevention, including screening and reporting notifiable diseases where relevant, and
3. carrying out health activities in a public setting in accordance with the National Board’s attached guidelines (see Appendix 1: Guideline in relation to health activities in a public setting).

6.5 Provision of care in a healthcare facility

Good practice involves:

1. seeking permission to access and provide care
2. adhering to and following the policies and procedures of the facility
3. communicating effectively with other practitioners involved in the management of the patient
4. keeping the the facility informed of any care
5. ensuring professional indemnity insurance (PII) coverage to cover care in that facility, and
6. keeping adequate records.

7.1 Introduction

Risk is inherent in healthcare. Minimising risk to patients is an important component of practice. Good practice involves understanding and applying the key principles of risk minimisation and management in practice.

7.2 Risk management

Good practice in relation to risk management involves:

1. being aware of the principles of open disclosure and a non-punitive approach to incident management (a useful reference is the Australian Commission on Safety and Quality in Health Care’s (ACSQHC) National Open Disclosure Standard⁴)
2. participating in systems of quality assurance and improvement
3. participating in systems for surveillance and monitoring of adverse events and ‘near misses’, including reporting such events
4. if a chiropractor has management responsibilities, making sure that systems are in place for raising concerns about risks to patients
5. working in practice and within systems to reduce error and improve the safety of patients, and supporting colleagues who raise concerns about the safety of patients, and
6. taking all reasonable steps to address the issue if there is reason to think that the safety of patients may be compromised.

⁴Available at the Australian Commission on Safety and Quality in Health Care website under Publications.

7.3 Chiropractor performance

The welfare of patients may be put at risk if a chiropractor is performing poorly. Good practice involves:

1. complying with statutory reporting requirements, including those under the National Law⁵
2. recognising and taking steps to minimise the risks of fatigue, including complying with relevant state and territory occupational health and safety legislation
3. following the guidance in Section 10.2 if a chiropractor knows or suspects that they have a health condition that could adversely affect their judgment or performance
4. taking steps to protect patients from being placed at risk of harm by a colleagues’ conduct, practise or ill health
5. taking appropriate steps to assist a colleague to receive help if there are concerns about the colleague’s performance or fitness to practise, and
6. if a chiropractor is not sure what to do, seeking advice from an experienced colleague, employer/s, practitioner health advisory service, professional indemnity insurer, the National Board or a professional organisation.

⁵Refer to the National Board’s Guidelines for mandatory notifications.

8.1 Introduction

Maintaining and developing knowledge, skills and professional behaviour are core aspects of good practice. This requires self-reflection and participation in relevant professional development, practice improvement and performance-appraisal processes to continually develop professional capabilities. These activities must continue through a chiropractor’s working life as science and technology develop and society changes.

8.2 Continuing professional development (CPD)

Development of knowledge, skills and professional behaviour must continue throughout a chiropractor’s working life. The National Law requires that chiropractors (and all of the regulated health professions) keep their knowledge and skills up to date through CPD to ensure that chiropractors can continue to work within their competence and scope of practice. Refer to the National Board’s registration standard and guidelines on CPD.⁶

⁶Available on the Chiropractic Board of Australia website under Registration standards and Codes and guidelines.

9.1 Introduction

In professional life, chiropractors must display a standard of behaviour that warrants the trust and respect of the community. Good practice involves:

1. observing and practising the principles of ethical conduct, and
2. practitioners conducting themselves appropriately in public while representing themselves as a registered chiropractor.

9.2 Professional boundaries

Professional boundaries allow a practitioner and a patient to engage safely in a therapeutic relationship.

Professional boundaries refers to the clear separation that should exist between a chiropractor’s professional conduct that is aimed at meeting the health needs of patients, and a chiropractor’s own personal views, feelings and relationships that are not relevant to the therapeutic relationship.

Professional boundaries are integral to a good chiropractor-patient relationship. They promote good care for patients and protect both parties. Good practice involves:

1. maintaining professional boundaries so that patients are not exploited financially, physically, emotionally or sexually.
2. never using a professional position to establish or pursue a sexual, exploitative or otherwise inappropriate relationship with anybody under a chiropractor’s care; this includes those close to the patient, such as their carer, guardian, spouse or the parent of a child patient
3. recognising that sexual relationships with people who have previously been patients are often inappropriate, depending on the extent of the professional relationship and the vulnerability of the person who was previously a patient, and
4. avoiding the expression of a chiropractor’s personal beliefs to patients in ways that exploit their vulnerability or that are likely to cause them distress.

9.3 Reporting requirements

Chiropractors have statutory responsibility under the National Law to report matters to the National Boards (refer to the National Board’s Guidelines for mandatory notifications⁷ and sections 130 and 141 of the National Law).

Chiropractors also have professional obligations to report to the National Board and their employer/s if they have had any limitations placed on their practice. Good practice involves:

1. being aware of the National Board’s reporting requirements
2. complying with any reporting requirements that apply to practice, and
3. seeking advice from the National Board, professional indemnity insurer or other relevant body if chiropractors are unsure about their obligations.

⁷Available on the Chiropractic Board of Australia website.

9.4 Health records

Maintaining clear, appropriate, factual, objective and accurate health records is essential for the continuing good care of patients. Detailed guidance on this matter is available in the Guidelines for clinical record-keeping for chiropractors published by the National Board. Chiropractors should be aware of relevant state and territory legislation in relation to health records management. Good practice involves:

1. keeping accurate, up-to-date, contemporaneous and legible records that report relevant details of clinical history, clinical findings and determinations, investigations, information given to patients, medication and other management details in a form that can be understood by other health practitioners
2. ensuring that records are held securely and are not subject to unauthorised access, regardless of whether they are held electronically and/or in hard copy
3. ensuring that records show respect for patients and do not include demeaning or derogatory remarks
4. ensuring that records contain sufficient information to allow another chiropractor to continue the management of the patient and to facilitate continuity of chiropractic care
5. making records at the time of events or as soon as possible afterwards and including a record of every patient consultation
6. ensuring that when a health record is to be changed, it is initialled, dated and tracked and, where possible, the previous entry is visible
7. recognising the right of patients to access information contained in their health records and facilitating that access
8. promptly facilitating the transfer of health information when requested by patients, and
9. ensuring when health records are destroyed it is done in a way that is compliant with any relevant state or territory legislation and the information is de-identified and unable to be retrieved.

9.5 Insurance

Chiropractors have a statutory requirement to ensure that they and their practice are appropriately covered by professional indemnity insurance (please refer to the National Board’s Professional indemnity insurance registration standard⁸). 

⁸Available on the Chiropractic Board of Australia website.

9.6 Advertising

Advertisements for services can be useful in providing information for patients. All advertisements must conform to relevant consumer protection legislation, and state and territory fair trading Acts and, if applicable, legislation regulating the advertising of therapeutic goods. In addition, the National Law is specific in its direction regarding the use of protected titles, including specialist titles. Good practice involves:

1. complying with the National Board’s Advertising guidelines⁹ and relevant state and territory legislation and Commonwealth law.
2. making sure that any information published about services is factual and verifiable
3. ensuring that when using a title, it is not used in a way that may mislead or deceive, for example the title ‘Doctor’/’Dr’ must only be used in a manner which clearly associates its use with the practice of chiropractic (e.g. Dr J Smith - Chiropractor). Also refer to Section 6.4 Advertising of qualifications and titles in the National Board’s Advertising guidelines, and
4. ensuring that business names or titles do not give the impression that the nominee is a specialist in an area of practice unless the chiropractor is recognised by the National Board as having relevant special expertise in the form of skills, knowledge, training or qualifications.

⁹Available on the Chiropractic Board of Australia website.

9.7 Legal, insurance and other assessments

When a chiropractor is contracted by a third party to provide a legal, insurance or other assessment of a person who is not their patient, the usual therapeutic chiropractor-patient relationship does not exist. In this situation, good practice involves:

1. applying the standards of professional behaviour described in this code to the assessment; in particular, being courteous, alert to the concerns of the person and ensuring the person’s consent
2. explaining to the person the chiropractor’s area of practice, role and the purpose, nature and extent of the assessment to be conducted
3. anticipating and seeking to correct any misunderstandings that the person may have about:
   1. the nature and purpose of the assessment and report, and
   2. the impartiality of the report (see Section 9.8 Reports, certificates and giving evidence)
4. recognising that the practitioner is likely to have a duty to report the findings to the party paying for the assessment, and
5. recognising that if an unrecognised, serious problem is discovered during the assessment, there is a duty of care to inform the patient and/or their treating practitioner.

9.8 Reports, certificates and giving evidence

The community places a great deal of trust in chiropractors. Consequently, chiropractors have been given the authority to sign documents such as sickness or fitness for work certificates, on the assumption that they will only sign statements that they know, or reasonably believe, to be true. Good practice involves:

1. only writing reports and certificates that are valid and accurate and in compliance with any relevant state or territory legislation
2. only signing documents believed to be accurate and current
3. taking reasonable steps to verify the content before signing a report or certificate and not deliberately omitting relevant information
4. if so agreed, preparing or signing documents and reports within a reasonable and justifiable timeframe, and
5. making clear the limits of a chiropractor’s knowledge and not giving opinion beyond those limits when providing evidence.

9.9 Curriculum vitae

When providing curriculum vitae, good practice involves:

1. providing accurate, truthful and verifiable information about a chiropractor’s experience and qualifications, and
2. not misrepresenting by misstatement or omission a chiropractor’s experience, qualifications or position.

Also see Section 11.3 Assessing colleagues in relation to providing references for colleagues.

9.10 Investigations

Chiropractors have responsibilities and rights relating to any legitimate investigation of their practice or that of a colleague. In meeting these responsibilities, it is advisable to seek legal advice or advice from a professional indemnity insurer. Professional conduct involves:

1. cooperating with any legitimate inquiry or investigation into the treatment/care of a patient, and
2. assisting the coroner when an inquest or inquiry is held into the death of a patient by responding to their enquiries and by offering all relevant information.

9.11 Conflicts of interest

Patients rely on the independence and trustworthiness of chiropractors for any advice or treatment/care offered. A conflict of interest in practice arises when a chiropractor, entrusted with acting in the interests of a patient, also has financial, professional or personal interests or relationships with third parties that may affect their care of the patient.

Multiple interests are common. They require identification, careful consideration, appropriate disclosure and accountability. When these interests compromise, or might reasonably be perceived by an independent observer to compromise the chiropractor’s primary duty to the patient, chiropractors must recognise and resolve this conflict in the best interests of the patient. Good practice involves:

1. recognising potential conflicts of interest that may arise in relation to initiating or continuing a professional relationship with a patient
2. acting in the best interests of patients when making referrals and when providing or arranging treatment/care
3. informing patients when a chiropractor has an interest that could affect, or could be perceived to affect, patient care or choice
4. recognising that marketing may influence chiropractors and being aware of ways in which their practice may be influenced
5. not asking for, or accepting, any inducement, gift or hospitality of more than minimal value from companies that sell or market products that may affect or be seen to affect the way chiropractors treat or refer patients
6. not asking for, or accepting, fees for meeting sales representatives
7. not offering inducements to colleagues or entering into arrangements that could be perceived to provide inducements, and
8. not allowing any financial or commercial interest in a hospital, other healthcare organisation or company providing healthcare services or products to adversely affect the way in which patients are treated: when chiropractors or their immediate family have such an interest, and that interest could be perceived to influence the care provided, chiropractors must inform their patients.

9.12 Financial and commercial dealings

Chiropractors must be honest and transparent in financial arrangements with patients. Good practice involves:

1. not exploiting the vulnerability or lack of knowledge of patients when providing or recommending services
2. not encouraging patients to give, lend or bequeath money or gifts that will benefit a chiropractor directly or indirectly
3. not becoming involved financially with patients; for example, through loans or investment schemes
4. not influencing patients or their families to make donations to other people or organisations in which the chiropractor has a pecuniary interest
5. not directly or indirectly sharing or agreeing to share fees paid by a patient with any other person who is not an employer, employee, principal or associate of the chiropractor, or receive other forms of remuneration, without the informed financial consent of the patient, and
6. being transparent in financial and commercial matters relating to work, including dealings with employers, insurers and other organisations or individuals and in particular:
   • declaring any relevant and material financial or commercial interest that a chiropractor or their family might have in any aspect of the care of the patient, and
   • declaring to patients any professional and financial interest in any product or service a chiropractor might endorse or sell from their practice, and not making an unjustifiable profit from the sale or endorsement.

10.1 Introduction

As a chiropractor, it is important to maintain health and wellbeing. This includes seeking an appropriate work–life balance.

10.2 Chiropractors’ health

Good practice involves:

1. attending an appropriate practitioner to meet health needs
2. seeking expert, independent, objective advice when a chiropractor needs healthcare and being aware of the risks of self-diagnosis and self-treatment/care
3. understanding the principles of immunisation against communicable diseases
4. recognising the impact of fatigue on a chiropractor’s health and ability to care for patients and endeavouring to work safe hours whenever possible
5. being aware of any practitioner health program in the relevant states and territories if advice or help is needed, and
6. if a chiropractor knows or suspects that they have a health condition or impairment that could adversely affect judgement, performance or the health of patients:
   • not relying on self-assessment of the risk posed to patients
   • consulting an appropriate health practitioner about whether, and in what ways, they may need to modify practice and following the treating practitioner’s advice, and
   • being aware of a chiropractor’s responsibility under the National Law to notify the National Board in relation to certain impairments.

10.3 Other practitioners’ health

Chiropractors have a responsibility to assist their colleagues to maintain good health. Good practice involves:

1. providing practitioners who are patients with the same quality of care provided to other patients
2. notifying the relevant National Board if treating another registered health practitioner who has placed patients at risk of substantial harm when practising their profession because they have an impairment (refer to the National Board’s Guidelines for mandatory notifications¹⁰); this is a professional responsibility, as well as a responsibility under the National Law
3. notifying the relevant National Board and encouraging a colleague (who is not a patient) to seek appropriate help if it is believed the colleague may be ill and/or impaired, and
4. recognising the impact of fatigue on the health of colleagues, including those under supervision, and facilitating safe working hours wherever possible.

¹⁰Available on the Chiropractic Board of Australia website.

11.1 Introduction

Teaching, supervising and mentoring chiropractors and students is important for their development and for the care of patients. It is part of good practice to contribute to these activities and provide support, assessment, feedback and supervision for colleagues, chiropractors-in-training and students. It also adds value to the supervisor’s practice through engagement with the person being supervised and their learning needs. There are a range of supervision models being adopted in the health professions, including coaching, mentoring, observing and shadowing.

11.2 Teaching and supervising

Good practice involves:

1. seeking to develop the skills, attitudes and practices of an effective teacher, whenever a chiropractor is involved in teaching
2. as a supervisor, recognising that the onus of supervision cannot be transferred
3. making sure that any chiropractor or student under supervision receives adequate oversight and feedback, including undertaking an assessment of each student supervised; reflecting on that student’s ability, competence and learning requirements; and planning their supervision based on that assessment rather than any external direction, and
4. avoiding any potential for conflict of interest in the supervisory relationship; for example, by supervising someone who is a close relative or friend, or where there is another potential conflict of interest that could impede objectivity and/or interfere with the supervised person’s achievement of learning outcomes or relevant experience.

11.3 Assessing colleagues

Assessing colleagues (including students) is an important part of making sure that the highest standards of practice are achieved. Good practice involves:

1. being honest, objective and constructive when assessing the performance of colleagues; patients will be put at risk of harm if an assessment describes as competent someone who is not, and
2. when giving references or writing reports about colleagues, providing accurate and justifiable information promptly and including all relevant information.

11.4 Students

Students are learning how best to care for patients. Creating opportunities for learning improves their clinical practice and nurtures the future workforce. Good practice involves:

1. treating students with respect and patience
2. making the scope of the student’s role in patient care clear to the student, to patients and to other members of the healthcare team, and
3. informing patients about the involvement of students and encouraging their consent for student participation, while respecting their right to choose not to consent.

12.1 Introduction

Research involving humans, their tissue samples or their health information is vital in improving the quality of healthcare, reducing uncertainty for patients now and in the future, and in improving the health of the population as a whole. Research in Australia is governed by guidelines issued in accordance with the National Health and Medical Research Council Act 1992 (Cth). Chiropractors undertaking research should familiarise themselves with, and follow, these guidelines. In addition, research involving animals is governed by legislation in states and territories, and by guidelines issued by the NHMRC.

12.2 Research ethics

Being involved in the design, organisation, conduct or reporting of health research involving humans brings particular responsibilities for chiropractors. Practitioners should refer to the NHMRC guidelines on this topic for detailed information.¹¹ The key responsibilities, drawn from the NHMRC guidelines, include:

1. providing participants the respect and protection that is due to them
2. acting with honesty and integrity
3. ensuring that any protocol for human research has been approved by a human research ethics committee, in accordance with the National statement on ethical conduct in human research issued by the NHMRC (which addresses privacy issues, and refers to the need to consider relevant state, territory and federal privacy legislation)
4. disclosing the sources and amounts of funding for research and any potential or actual conflicts of interest to the human research ethics committee
5. ensuring that human participation is voluntary and based on informed consent and an adequate understanding of sufficient information about the purpose, methods, demands, risks and potential benefits of the research
6. ensuring that any dependent relationship between chiropractors and their patients is taken into account in the recruitment of patients as research participants
7. seeking advice when research involves children or adults who are not able to give informed consent to ensure that there are appropriate safeguards in place, including ensuring that a person empowered to make decisions on the behalf of patients has given informed consent or that there is other lawful authority to proceed
8. adhering to the approved research protocol
9. monitoring the progress of the research and reporting adverse events or unexpected outcomes promptly
10. respecting the entitlement of research participants to withdraw from any research at any time and without giving reasons
11. adhering to the guidelines regarding publication of findings, authorship and peer review, and
12. reporting possible fraud or misconduct in research as required under the Australian code for the responsible conduct of research issued by the NHMRC.

¹¹National Health and Medical Research Council.

12.3 Treating chiropractors and research

When chiropractors are involved in research that involves patients, good practice includes:

1. understanding and complying with the guidance set out in Section 12.2 Research ethics
2. respecting the right of patients to withdraw from a study without prejudice to their treatment/care, and
3. ensuring that a decision by patients not to participate does not compromise the chiropractor–patient relationship or the care of the patient.

The Chiropractic Board of Australia acknowledges with appreciation the following publications that have been consulted in the preparation of this code:

• Australian Health Practitioner Regulation Agency. Code of conduct for registered health practitioners
• Australian Medical Council 2009. Good medical practice: a code of conduct for doctors in Australia
• ACT Allied Health Professions 2004. Standards of practice
• the Health Practitioner Regulation National Law, as in force in each state and territory
• various Acts and Regulations in each state and territory that have a direct or indirect impact on the conduct of practitioners, including (but not limited to) mandatory reporting of child abuse, freedom of information, equal opportunity, privacy and public records
• common law principles and decisions relating to matters such as consent, negligence, duty of care, contract law and vicarious liability, and
• various state and territory-based codes and guidelines that regulated the practice of chiropractic in various jurisdictions around Australia before the National Scheme.

Electronic means any digital form of communication, including email, Skype, internet, social media, etc.

Evidence-based healthcare is the integration of the best available evidence with professional expertise, in conjunction with patient preference, values and circumstances, to make healthcare decisions.

Patient includes client and health consumer.

Patient centred implies being respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient need and values guide the decision-making for that patient.

Practice means any role, whether remunerated or not, in which the individual uses their skills and knowledge as a chiropractor in their regulated health profession. For the purposes of this code, practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with patients, working in management, administration, education, research, advisory, regulatory or policy development roles, and any other roles that have an impact on safe, effective delivery of health services in the chiropractic profession.

Providing care includes, but is not limited to, any treatment/care, advice, service or goods provided in respect of the physical or mental health of a person, whether remunerated or not.

Red flags are findings which may indicate a more extensive disease process that should attract a clinician’s attention as a matter of priority.

Social media describes the online and mobile tools that people use to share opinions, information, experiences, images, and video or audio clips and includes websites and applications used for social networking. Common sources of social media include, but are not limited to, social networking sites such as Facebook and LinkedIn, blogs (personal, professional and those published anonymously), WOMO, True Local and microblogs such as Twitter, content-sharing websites such as YouTube and
Instagram, and discussion forums and message boards.

Treatment, care, management and healthcare services are terms that can be used interchangeably for the purposes of this code.

The aim of this appendix is to assist chiropractors in performing health activities in a public setting in a safe and responsible manner. Chiropractors undertaking health activities in a public setting should also be aware of, and comply with, the provisions of the Health Practitioner Regulation National Law, as in force in each state and territory (the National Law) that relate to advertising, the Code of conduct as a whole, with particular reference to Sections 6.4, 9.1 and 9.2, and the National Board’s Guidelines for advertising regulated health services (the Advertising guidelines), which can be found on the Codes and Guidelines page.

Health activities in a public setting

For the purposes of this appendix, health activities in a public setting means any activity that involves a chiropractor offering a service of either assessing the health of another party or providing health information (including spinal screenings) in a public setting for the purposes of promoting the health of the public. For the purpose of this code, a public setting for this activity would be deemed to be somewhere separate from the place where a practitioner might normally conduct paid clinical consultations.

Health activities in a public setting are fundamentally undertaken to disseminate information and understanding of health-related matters to the public and to carry out relevant health assessments in a public setting.

These activities must be undertaken in the public interest and seek to promote the health of the public and therefore must not be seen to have a direct promotional benefit to the practitioner(s) carrying out the activity. Examples of where a health activity in a public setting may be perceived as promotional may include but are not limited to; the use of practitioner-specific signage, use of letterheads, stamped brochures, business cards as part of the public health activity etc.

It is the responsibility of the individuals involved to ensure that, if required, all necessary permits are in place before starting a health activity in a public setting. No notification to the Chiropractic Board of Australia (the National Board) is necessary.

While the content and materials associated with a health activity in a public setting are not necessarily deemed as advertising for the purposes of the Advertising guidelines, it is expected that the material provided as part of such activities should in principle, be consistent with these guidelines.

Good practice in relation to health activities in a public setting involves:

1. ensuring that any information provided to participants is not false, misleading, deceptive or
   elicits unwarranted fear in the mind of the participant
2. providing the participant with contact details at their request, but should not include obtaining
   contact information from participants or the making of appointments at the time of the activity
3. not making unsolicited contact with participants after a public health activity
4. any screening, analysis or advice only being performed by a registered chiropractor or a
   registered student participating in an approved supervised practice program (students should
   be in their final year of study in an approved program)
5. ensuring that members of the public are aware of the purpose of, and the limitations of the
   health activity, e.g. ensuring that members of the public are aware that the purpose of a spinal
   screening is to give the participant an overview of the general state of their posture and is not
   a comprehensive spinal examination
6. no fee being charged for the activity, and
7. practitioners providing balanced, non-biased and evidence-based information in order to enable members of the public to make informed health decisions and considerations.

For the purposes of this appendix promotional activities are defined as any activities undertaken by a practitioner in any setting that confer a direct promotional benefit to the practitioner(s) involved.

These activities must comply with the National Law, the Code of conduct, with particular reference to Sections 6.4, 9.1 and 9.2, and the Advertising guidelines, which can be found on the Chiropractic Board of Australia website.

Good practice in relation to promotional activities includes the good practice principles for health activities in a public setting (a) to (g) above and strict adherence to the Advertising guidelines. Practitioners must also ensure that the promotional activity is represented as a promotional activity.

Spinal screenings may be either a health activity or a promotional activity dependent upon the characteristics of each event.

Radiographic imaging is part of the suite of diagnostic procedures offered by chiropractors, either in a chiropractic office or through referral.

Chiropractors use radiography for several purposes following the identification of various history and examination findings, including: confirmation of diagnosis/pathology; determining appropriateness of care and; identifying contraindications or factors that would affect or modify the type of treatment/care proposed.

The aim of this guideline is to assist chiropractors in referring for, and undertaking, radiology and radiography procedures in a safe and responsible manner.

Chiropractors must comply with the provisions of the code of practice for radiation protection and the Application of ionizing radiation by chiropractors (2009) or any subsequent version as published by the Australian Radiation Protection and Nuclear Safety Agency (ARPANSA Code), and applicable Commonwealth, state or territory laws in relation to best practice (see www.arpansa.gov.au under Publications).

The Chiropractic Board of Australia (the National Board) recommends that practitioners note the following points from the ARPANSA Code:

1. The key purposes of the ARPANSA Code are to:

• establish radiation protection principles (including the necessity to maintain equipment in accordance with applicable state and territory legislation).
• establish the regulatory requirements for the application of ionising radiation, in the context of good practice, to ensure that risks associated with radiation exposure to the patient are optimised and are as low as reasonably achievable
• set the requirements for a comprehensive Radiation Management Plan
• establish the roles and responsibilities of persons involved in the process, including the chiropractor as the person responsible for the justification and optimisation of the procedure, and
• establish a process for the management and reporting of radiation incidents.

2. The key radiation protection principles of the ARPANSA Code are:

Justification - No practice involving exposure to radiation should be adopted unless it produces sufficient benefit to the exposed individuals or to society to offset the radiation detriment it causes – the procedure must be justified for that individual patient.

Optimisation - Radiation doses must be kept ‘as low as reasonably achievable’ (ALARA).

Dose limits - Applications of ionising radiation must be managed in a way so as not to exceed dose limits specified in RPS1.

Additional key points in relation to radiology/radiography

In addition to the ARPANSA Code, the National Board reaffirms and clarifies the following points:

1. Before a procedure involving exposure of an individual to ionising radiation is approved or commenced the indications for it must be clinically justified by the chiropractor in an evidence-based context.
2. Exposure to radiation should not be adopted unless it produces sufficient benefit to the exposed individuals or to society to offset the radiation detriment it may cause.

The ultimate judgement regarding the application of any radiation-based procedure must be made by the chiropractor in light of all the circumstances presented and in an evidence-based context.

The aim of this guideline is to assist chiropractors in their clinical decision-making. This section should be read in close conjunction with Sections 2.1 and 2.2.

The Chiropractic Board of Australia (the National Board) supports and recommends that practitioners are familiar with the following key points:

1. A program of care should be developed in a patient-centred and evidence-based context and:

• be based on clinical need
• be consistent with accepted standards of chiropractic care by the profession
• be tailored to the specific needs and expectations of each patient
• consider the natural history of the condition
• be based on a reasonable clinical impression/diagnosis
• include any proposed management
• include expected measurable outcome of care
• include a reasonable estimate of the timeframe for achieving expected outcomes
• include a plan for review/reassessment, and
• when clinically indicated, include details of any co-management and/or referral.

2. Review/reassessment should be periodic, and should include:

• validated objective and subjective outcome measures
• evaluation of the benefit of care to the patient
• identification of whether the original diagnosis/clinical impression should be modified (this may indicate a need for a reassessment, change in treatment/care/procedure or the obtaining of a second opinion or referral)
• clinical justification for care to continue, or not
• the number of further visits proposed (which should be appropriate, necessary and not arbitrary or excessive), and
• an understanding and agreement by the patient of the aims surrounding the proposed program of care.

3. A patient may elect some form of ongoing or supporting treatment/care as a part of their overall health management. This form of care has the same requirements in relation to informed consent and explanation of anticipated outcomes as any other care.

4. Should any patient elect to undergo regular chiropractic examination or treatment/care in the absence of symptoms, it is the responsibility of the practitioner to provide the patient (parent/guardian for children) with a balanced, evidence-based view of the clinical justification for such procedures.