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Reporting Guideline

Initiative
VvOCM (Association of Cesar and Mensendieck Exercise Therapists)

Organization
VvOCM

Financing
This guideline was financed by VvOCM
Colophon
Reporting Guideline Updated
version spring 2022

© Copyright 2022
VvOCM (Association of Exercise Therapists Cesar and Mensendieck)
Orteliuslaan 750
3528 BB Utrecht
tel: 030-2625627
Website: www.vvocm.nl
E-mail address: [email protected]

All rights reserved.

The text from this publication may not be reproduced, stored in a retrieval system, made public
in any form or by any means, electronic, mechanical, photocopying or otherwise, but only with
the prior permission of the publisher. Permission to use text (parts) can be requested in writing
or by e-mail and exclusively from the publisher. Address and email address: see above.

The Association of Exercise Therapists Cesar and Mensendieck aims to create the conditions
under which good quality exercise therapy care is achieved, which is accessible to the entire
Dutch population, with recognition of the professional expertise of the exercise therapist.

VvOCM Reporting Guideline 2022

Table of contents

Involved persons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Part I – Practical Guideline for Reporting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Methodical exercise therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Steps 1 and 2 – Registration and history. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Step 3 – Exercise therapy research. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Step 4 –
exercise therapy diagnosis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Step 5 –
Treatment goal and treatment plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Step 6
– treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 Steps 7 and 8 –
Evaluation and Closure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

Part II – Explanation and Justification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Explanation of file requirements for methodical action. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Clinimetry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Formulate SMART. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
SOUP/SOAP structure. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Reporting in relation to guidelines and protocols. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Reports. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Multiple treatment processes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Relevant legislation and regulations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Medical Treatment Agreement Act (WGBO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
General Data Protection Regulation (GDPR). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26
Domestic violence and child abuse reporting code and assessment framework
. . . . . . . . . . . . . . . . . . . . . . . . . .27 Individual Healthcare Professions Act (BIG). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Use of Citizen Service Number in Healthcare Act (Wbsn-z). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .28

Healthcare Quality, Complaints and Disputes Act (Wkkgz). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31

VvOCM Reporting Guideline 2022

Involved persons

Authors
Mrs. TJM Kooiman Policy officer/guideline advisor VvOCM
Mrs. G. Buis Advisor, author of guideline reporting 2014
Mrs. D. Conijn Policy officer/guideline advisor VvOCM

Content support
Mrs. NTA Smorenburg Teacher training Cesar Exercise Therapy, Utrecht University of Applied Sciences
and exercise therapist at Cesar Zaltbommel Exercise Therapy, Zaltbommel

Sounding board group

Exercise therapy courses
Mrs. NTA Smorenburg Lecturer in Exercise Therapy Cesar, Utrecht University of Applied Sciences. Teacher-
Mrs. MSH Wortman researcher Lecturer 'Exercise Therapy - Daily Exercise!', Amsterdam University of
Applied Sciences and co-developer in Exercise Therapy training, Windesheim
University of Applied Sciences

Workfield
Mrs. LA Alberts Exercise Therapist Mensendieck, Therapy Wolf, Texel Exercise Therapist
Mrs. M. Bavelaar Mensendieck, Exercise Therapy Alphen, Alphen aan den Rijn Exercise Therapist
Mr. HG van den Boogaard Mensendieck, Exercise Therapy van den Boogaard, Almere Exercise Therapist
Mrs. S. van der Drift Cesar, Pract'S Exercise Therapy, Haarlem
Mrs. TPM Hillebrink Psychosomatic Exercise Therapist, Exercise Therapy Zaanstad, Zaandam
Mrs. CJ Kunis-Loos Exercise Therapist Mensendieck, exercise therapy TOBB, Heerhugowaard
Mrs. HL van Schie Exercise Therapist, pelvic exercise therapist, (child) sleep exercise therapist,
Bewuster Bewegen practice, Koudekerk aan den Rijn
Mrs. F. van der Velde Exercise therapist Cesar, OCG, Groningen

Contact persons office VvOCM

Mrs. TJM Kooiman Policy officer/guideline advisor VvOCM
Mrs. V. Zegers Director VvOCM

VvOCM Reporting Guideline 2022

4
Introduction

Cause
The broad health domain in which the exercise therapist works is continuously developing. The
Administrative Agreements on Paramedical Care 2019-2022 (Rijksoverheid.nl, 2019) directs
paramedic-wide coordination on information transfer and data exchange. An example is the
publication of the HASP paramedic guideline in 2020, which describes the exchange of information
between general practitioners and paramedics. These developments have consequences for how
the exercise therapist processes information in the patient file.
At the same time, research by VvOCM has shown that exercise therapists need administrative
burden relief in order to increase productivity (billable hours) and job satisfaction.

Together, these developments formed the reason to update the Reporting Guideline for
exercise therapists.

Objectives of the Reporting Directive

• To provide guidance to exercise therapists for the systematic recording of data and
findings regarding exercise therapy care so that this care is transparent and
is transferable, and complies with applicable laws and regulations.
• Promoting uniform reporting on client care, including paramedics-wide.
• Providing a basis for updated or newly developed health care guidelines.
• Serve as the basis for NIVEL care registrations and the National Exercise Therapy Database. Serve
• as a basis for assessment criteria in the event of file assessment.

This guideline indicates which data must be recorded in the file, both from the methodical approach
of the Professional Profile of the Exercise Therapist (VvOCM, 2019) and from legislation and
regulations.

Target audience

The guideline has been drawn up for all exercise therapists in both primary and secondary care. The
guideline basically applies to every care process, although adjustments may of course be necessary
for specific client groups. Adjustments to reporting may also be necessary based on agreements
within the various specializations of exercise therapy (the Pediatric Exercise Therapy platform, the
Psychosomatic Exercise Therapy platform, the Geriatric Exercise Therapy platform, the Pelvic
Exercise Therapy platform) and networks such as the Chronic Pain Network. Deviations from the
guideline may also occur as a result of agreements within chain care, other interdisciplinary
partnerships or within intramural interprofessional work settings.

VvOCM Reporting Guideline 2022

5
History Reporting Guideline
The Reporting Guideline was drawn up in 2014 with the help of a broad working group that represented
the entire field. A draft version has been drawn up based on existing documents, requirements for
guidelines at the time, developments in healthcare registrations (e.g. at NIVEL) and the input of the
working group. This draft version was subsequently commented on in several rounds by the working
group and steering group and subsequently adjusted accordingly.
The guideline was updated in 2017 and 2019 based on new legislation and regulations, such as the GDPR and
the Domestic Violence and Child Abuse Reporting Code.

Method for updating the Reporting Guideline 2022

The user-friendliness of a guideline is important to reduce administrative burdens. When
information in a guideline is easy to look up, it can be applied in a more time-efficient manner.

For the current update, the KNGF-VvOCM guideline methodology (Vreeken et al, 2022) is
therefore used to adapt the entire structure of the guideline. In Part I (Practical Guideline), the
exercise therapist can find directly applicable information regarding reporting in the file. The
file requirements are linked to important models within exercise therapy, namely the Exercise
Therapy Diagnostics and Intervention Model (ODIM) and the ICF model. The guideline will also
provide tools for concisely recording data, which also saves time. Part II (Explanation and
Justification) contains information about relevant paramedic-wide developments, an
explanation of the file requirements within methodical action, and relevant legislation and
regulations.
In addition, we have joined interdisciplinary, paramedical-wide task groups so that the current
version of the guideline is in line with the latest developments.
The current sounding board group for Guideline Reporting consisted of three participants from the 2014
sounding board group and a number of other exercise therapists. The sounding board group assessed
the current amended guideline in one round. This feedback was then incorporated into the guideline. On
March 11, 2022, this updated guideline was presented to the board of VvOCM for approval. This guideline
was adopted by the members of VvOCM during the General Meeting (AGM) on June 15, 2022.

Implementation
A crucial part of implementing the Reporting Directive is reconnecting with EPD systems. All
EPD suppliers will be approached to make desired adjustments to the software systems.
Connection with the EPD suppliers is also being addressed across the Paramedic sector within
the 'generic dataset' working group. In addition, there is contact with EPD suppliers in the
guideline implementation process to promote general implementation of guidelines in EPD
systems.

VvOCM Reporting Guideline 2022

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Part 1

Practice guideline
Reporting
This chapter describes all the data that the exercise therapist records during all steps of
methodical exercise therapy. These are both administrative and healthcare-related data.

r a distinction is made between:

•
E Mandatory information (v): this information is always mandatory(from the Medical Treatment
Agreement Act (WGBO))and can be used both administratively and in terms of healthcare content

• Required dataif these are present and relevant(i). This information does not always apply
be in nature.

to every client, and is therefore only mandatory when applicable. This is possible
are both administrative and healthcare-related data.
• Optional data. These are, for example, personal work notes that the therapist uses as temporary
memory aid. This falls outside the scope of this guideline.

VvOCM Reporting Guideline 2022

7
The exercise therapeutic methodical action
Figure 1 shows the Exercise Therapy Diagnostics and Intervention Model (ODIM)
(Bastiaansenten Haaf, C., Smorenburg, 2015). This model illustrates the total care provider
process of the exercise therapist. The data to be recorded is then described per phase and
steps of methodical action.

ORIENTATION

DIAGNOSTIC PHASE(0 measurement - kli nimetry)

DTO Reference

Clarify client's request for assistance 1

Screening
fluff? Yes
Additionalanamnesis 2
no Motivation

ANALYSIS
Stop therapy
AO:Analysis of problem activity/action in context 3 Mobility Move- Cognition
behaviour

Environment
SO:Perform diagnostic tests 4

DEFINITION
no
Stop therapy To formulateOTD,andindicationtherapy? 5

Yes
Formulategoalandplan 6

SOLUTION

INTERVENTION PHASE(evaluation of interim and final measurements, reporting)

Practice on Behavioral Conversational
activity level change techniques
in and out of context
Motivation/Emotion
models

Coaching to Coaching Coaching

other to other
exercise behavior move-
behaviour
To influence
Mobility Cognition
Simultaneously Exercise behavior
practice on To cancel/
activities and Reduce
job level Physical
limit
Environment
Practice on
job level
as soon as possible Practice in Dealing with an environment Environmental restriction Advice
practice on the context/ that cannot be adapted to cancel/
activity level advice Reduce

Exercise Therapy Diagnostics & Intervention Model

©CJM ten Haaf & NTA Smorenburg, 2012 Hogeschoool Utrecht
–87

Figure 1. Exercise Therapy Diagnostics & Intervention Model

Diagnostic phase
In this phase, the exercise therapist wanted to gain insight into the health problem, the requests for help
and factors that may influence the health problem. The exercise therapist forms an idea of the treatable
components (motor skills, environment, motivation, cognition) in relation to the request for help and
problem action(s) and of possible factors that promote and hinder recovery. The exercise therapist also
determines whether or not there is an indication for exercise therapy and whether the problem falls
within their own expertise (VvOCM, 2019).

The exercise therapist uses measuring instruments when making clinical choices. These
measuring instruments are based on recommendations from an applicable guideline or are
applied at your own discretion. For further explanation, see Part II Explanation & Justification.

VvOCM Reporting Guideline 2022

8
Steps 1 and 2 – Registration and history
The client comes to the exercise therapist (DTO) on a referral from the doctor or medical specialist or on his
own initiative (or on the advice of third parties). If the client registers via DTO, the exercise therapist will carry
out a screening (VvOCM and KNGF, 2006). The method of registration therefore has consequences for the data
to be recorded.

Data to be recorded (both upon referral and DTO) (v)

• Surname + initials
• Client's date of birth
• BSN number
• Date of registration
•
•
General practitioner: name

Request for assistance from the client.The request for help is definitively formulated after the anamnesis.

Additional data to be recorded at DTO (v)

• Contact reason.
• Conclusion screening . (fluff/non-fluff)

• Abnormal symptoms/abnormal course (i) (if screening conclusion is 'incorrect').

• Indication for further exercise therapy . (Yes No)

• Evidence of chronic condition (i).

• Client consent to sharing data with or by the GP (Yes No). The DTO message
• sent to the GP (only if permission is given).

Within theGuideline for information exchange between doctors and paramedics (NHG, 2020) it has been
agreed to send a message to the GP with Direct Access (NHG, 2020). This can be done very briefly.

To be additionally recorded upon referral (v)

• Referrer: name and specialization.
Preferably including the first two positions AGB care provider code, e.g. 01=GP, 03=medical specialist.

• Reason + context reference.

• Additional (medical) information provided by the referrer (i).
• Procedural proposal (i) .
(this is the referrer's question)

Data to be recorded from the additional anamnesis (v)

The additional anamnesis further clarifies the health problem/complaints and the request for
help. The exercise therapist uses the ICF model (figure 2) and the ODIM (figure 1). To clarify the
connection with the ICF and the ODIM, the data to be recorded is shown schematically in
relation to these models. In addition, the results from measuring instruments administered
during the anamnesis are noted in the file, including the date (i).

VvOCM Reporting Guideline 2022

9
 disorders, diseases

functions and anatomical

activities participation
characteristics

external factors personal factors

Figure 2. The ICF model

ICF domain ODIM domain Data to be recorded

Conditions/disease The condition or illness for which the client is
being treated (i).

Features & anatomical Mobility Health problem/complaint in relation to reason

characteristics for contact.
Relevant information about the origin of the
complaints and/or problem, including duration,
course, recurrence(Yes No)and previous interventions (i).

Activities Mobility & Functioning problems: the nature and severity

Environment of the problem in the daily context, including
exercise behavior (i).

Participation Mobility & Participation problems in relation to

Environment the health problem/complaints (i).
Personal factors Motivation/emotion Relevant personal factors such as
& Cognition secondary pathology, contraindications,
medication use*, profession, coping style,
motivation, lifestyle (BRAVO factors),
cognition, mood/emotions (incl.
psychosocial factors), behavior, social and/
or cultural background, experiences,
character , education level (i).

External factors Motivation/emotion Relevant environmental factors such as influence of

& Environment social and physical environment, description of work
situation, home situation and risk factors (i).
* Type and amount of medications that may influence the
recovery process or the choice of interventions

VvOCM Reporting Guideline 2022

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Other information required for authorization and declaration transactions
• Other client/insured data: gender, address, client identification number.
The client identification number is automatically generated by the EPD program.

• Healthcare provider: Unique Healthcare Provider Identification (UZI) practitioner/AGB number.

• Health insurer: Unique Health Insurer Identification (UZOVI number).

• Care provided: referral date, date of performance(s); code performance(s); amount declaration.

• Indication (code).
• Accident indication (i).

• Diagnosis code according to the paramedical aid diagnosis coding system (DCSPH).

Step 3 – Exercise therapy research

The exercise therapy examination consists of an Activity Examination (AO) and a Specific
Examination (SO).

Activity research
In the activity study, the exercise therapist forms a picture of the problem action by means of a task
analysis and an environmental analysis to determine the extent to which the task and/or
environment (context) influences exercise behavior. Through observations in the (physical)
environment or an imitation of that environment or through standardized performance tests (e.g.
the Timed Up & Go test), the therapist gets an impression of the specific way of straining and the
client's load capacity at that moment.

Specific research
In the specific study, the exercise therapist uses observations, physical measurements and
standardized tests to form a picture of the generalized and local state of the movement system
(and movement-related systems): type and degree of variability of movement strategies,
(dis)balance in load-bearing capacity, deficiencies in, for example, proprioception, coordination,
strength, flexibility, alertness, muscle activity, relaxation and breathing. The aim is to rule out
(other) pathology, to confirm the diagnosis, to estimate the physical capacity and to find out
whether there are compensations and adaptations.

Data to be recorded for activities and specific research (v)

• All diagnostic procedures that, in the opinion of the exercise therapist, are relevant to
arriving at an exercise therapy diagnosis are noted.
- Most important findings from observations of problem actions.
- Results/test scores of used measuring instruments, observations, diagnostic tests,
palpations and/or standardized performance tests.
• All diagnostic procedures that are performed at a later time and are relevant to the recovery
process (including date, location and condition of the client) (i).

VvOCM Reporting Guideline 2022

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Step 4 – exercise therapy diagnosis
The exercise therapy diagnosis is the profession-specific assessment based on the clinical
reasoning process. During the diagnostic process, the therapist analyses, organizes and
interprets the information from the anamnesis and the examination. The therapist describes
the health problem in relation to the findings of all (relevant) ICF and ODIM domains. The
exercise therapist can use various tools, such as the Rehabilitation Problem Solving form (RPS).

Data to be recorded in the exercise therapy diagnosis (v)

• The client: gender, age, referral diagnosis/complaint (DTO), request for assistance.

• Relevant findings from anamnesis and research in conjunction, or: the profession-specific
analysis + conclusion.
The conclusion includes a concise summary of the exercise therapy diagnosis in which the treatable components of the client
case become visible. This conclusion is also used in correspondence with the GP/referrer.

• Factors that hinder recovery (i) that may influence the treatment.
- Personal factors such as lifestyle, motivation, cognition, psychosocial factors and co-morbidity.
- External factors such as the physical and social environment.

• Recovery-promoting factors (i) that may influence the treatment.

- Personal factors such as lifestyle and motivation.
- External factors such as the physical and social environment.

• Prognosis for recovery (i) (complete recovery, reduction of complaints, stabilization, cannot be determined).

Based on the findings, the exercise therapist decides whether there is an indication for exercise
therapy treatment, or whether (re)referral to the GP or other healthcare provider is necessary.

Other data to be recorded (v)

• Indication for exercise therapy (yes/no).
• Referral to fellow exercise therapist/other discipline or (re)referral from GP/other advice
(i).

Intervention phase
If there is an indication for exercise therapy, the treatment goal and a treatment plan are
drawn up in step five of the care provision process. The exercise therapist uses available
guidelines as a guideline for drawing up the treatment plan. The plan is then implemented,
evaluated and adjusted if necessary (step 6) and evaluated and completed in consultation with
the client (steps 7 and 8).

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Step 5 – Treatment goal and treatment plan

The general treatment goal specifies the intended end result and preferably relates to resolving
limitations in activities and participation (ICF). The exercise therapist formulates subgoals at
function level (Motor skills) and at activity and participation level (Motor skills & Environment;
motor skills within activities and environmental factors). Behavior-oriented goals can also be set
to improve exercise behavior and/or promote motivation, perceptions, lifestyle and self-
management (Motivation/emotion & Cognition). Achieving subgoals contributes to achieving
the general treatment goal.

Data to be recorded for treatment goal and treatment plan (v)

• Amain goalin which the intended (end) result is specifically stated. The relationship with the
request for help and findings from the research is clear. The main objective is formulated
SMART if possible (see Part II Explanation & Justification for an explanation/nuance).
on the use of SMART).
• Ittreatment plan: the chosen treatment strategy to achieve the intended treatment goal. The
treatment plan shows a basic planning of the sequence over time. The treatment plan includes:
- Sub-goals from relevant areas of interest: functions, activities/participation (motor skills and
environment) and behavior (motivation/emotion and cognition).
A possible exception to this is a simple request for help and a short treatment time.

- Adjustments/resources needed to achieve the goals (i).

- An evaluation system:
- Agreements on moments of evaluation and how/with which measuring instruments.
- Criteria based on which steps are taken (i), e.g. termination of treatment.

• Use of protocols and guidelines (i)

- According to which protocol or guideline is being worked (title, version number or date appear) (i).
- Deviation from explicit recommendations regarding diagnostic tests and evaluative
measuring instruments (i).
- Deviating from explicit recommendations about (type of) treatment interventions and contraindications (i).
• Forecast in time
- An estimate of the number of treatment sessions required to achieve the treatment goal.
- Duration in weeks or months of the treatment process (i). Frequency per week/month including any
reduction (i).
• Agreements
- With the client (i).
- With other disciplines (i). Discussed
• with and agreed by client.
Here, a check mark in the file is sufficient, possibly with a (digital) signature of the client. Part II provides an explanation of the
legal consent requirement.

Other data to be recorded (v)

• Consent, agreement to request/provide data.

VvOCM Reporting Guideline 2022

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Step 6 – treatment
With the treatment plan as a guideline, the actual treatment takes place in this phase. The
therapist determines session goals, a structure of the treatment sessions and carries out
various procedures. Details about the implementation are recorded in the daily journals. The
journals must briefly indicate in a systematic manner what the client's experiences are, what
the content of the treatment session was and how it went (v). Other information is only
required if it is relevant (i).

In practice, most EPDs use the SOEP(A)/SOAP structure. This stands for Subjective-Objective-
Evaluation/Analysis-Plan-(Activities). The data to be recorded is shown below in relation to this
structure.The use of the SOEP(A) structure is therefore not an obligation, but a tool. The daily
journal can also be entered within a single input field within the EPD.See Part II (Background
and Explanation) for more information and background on the SOEP(A) structure.

Data to be recorded (v)

•
S subjective
Client experience since previous session.

•
O subjective

Procedures performed during the treatment session.

If SOEPA is used, this falls under Activities.

• Interim diagnostics or measurement results according to the chosen evaluation system (i).
Only if these results are not visible elsewhere in the file with date.

•
E valuation
Evaluation of the progress of procedures performed according to therapist and client.
E.g. an evaluation of the client's learning behavior, course of the treatment session or, if necessary, of the client's own actions/didactics used.

•
P lan
Agreements with client for the period until the next treatment (i). Points of

• attention for next treatment session/deviation from plan (i).

If the treatment plan is significantly modified, it is preferable to add the change to the treatment plan (with date) instead of in
the daily journal.

• Decision whether or not to continue the treatment plan based on the measurement results(i).

•
O verg
Result of (oral) consultation with GP/referrer (i).
The results of a consultation can also be placed under 'Objective'.

• Update of treatment progress to the referrer (i).

The message/interim evaluation sent to the referrer.

Within the Information Exchange Guideline between doctors and paramedics, it is recommended
that if a client is in treatment for a long period of time, an annual update/progress report is sent to
the GP (NHG, 2020).

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Steps 7 and 8 – Evaluation and Closure
The evaluation consists of a product evaluation and a process evaluation (step 7). The product evaluation
concerns the extent to which the set goals have been achieved, the client's assessment of the change in
the complaint and the exercise therapist's assessment of the behavioral change. The exercise therapist
also uses measuring instruments here.
The process evaluation is the examination of how all activities that have been part of the methodical
exercise therapy have progressed in terms of content and organization and in terms of treatment
aspects.
The exercise therapist concludes the treatment episode together with the client (step 8). The
therapist discusses recidivism policy, possible aftercare and reporting. The therapist corresponds
about the results achieved/termination of the therapy with the referrer (for referral) or general
practitioner (for DTO). The client must give permission for this data exchange. This permission can
be given both verbally and in writing.

data to be recorded during evaluation and closure (v)

V• Date of final evaluation.

• Reason for end of care.

• Treatment result: achieving treatment goal; objective measurement result (i).

• Treatment process (i).

• Recidivism policy (i).

• Aftercare options (i).

• Reporting: the final report sent to the GP/referrer.
When exchanging information with the GP, the exercise therapist preferably uses the Guideline for
information exchange between doctors and paramedics (HASP paramedic) (NHG, 2020). See Part II
Explanation and Justification for an explanation of this guideline.

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Part II

Explanation and
Accountability
Introduction

Part II of the Reporting Guideline further explains the data to be recorded in exercise therapy
client files and relevant legislation and regulations. An explanation is also given here of
agreements made within the Administrative Agreements on Paramedical Care 2019-2022,
which (may) influence the exercise therapy reporting.

Administrative Agreements
In the strategic policy plan 2021-2023, VvOCM has described the participation of Paramedical Platform
Netherlands (PPN) in the Administrative Agreements (VvOCM, 2020). Participating parties are VWS,
Patient Federation, ZN, PPN, and the KNGF (incl. SKF). The Administrative Agreements consist of six
chapters:
1. The right care in the right place
2. Quality of care
3. Information for the patient
4. Degree of organization

5. Digitization
6. Other (various agreements on regulatory burden, cost research and rate development).

There is active participation in work and research for the VvOCM Quality and Science portfolio
task groups from Chapter 2 'Quality of Care'. VvOCM has the task to:
• Develop quality standards and promote (streamlining) guideline development.
• Implement the knowledge that has been developed in the care practice of the exercise therapist.

• Encouraging data collection with which data is recorded in a structured manner for the
purpose of transparency of the quality of care.

In the context of these objectives, VvOCM participates, among other things, in the development and
implementation of the General Practitioner-Paramedic Information Exchange Guideline (HASP-
paramedic) and the Task Group 'Generic dataset for Paramedical Care' (GDPZ). The aim of this task
group is to develop a generic dataset for paramedics, so that information exchange is simplified and
participation in research becomes possible.
These developments have been incorporated into the current update of the Reporting
Guideline, so that current developments are implemented in the care practice of the exercise
therapist. It is expected that the Reporting Guideline will be updated again in the future based
on further outcomes of these projects. The same applies to future developments in, for
example, the Personal Health Environment (PHE).

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VvOCM work agenda
In addition, the externally conducted cost study among exercise therapists has shown that the
productivity (percentage of billable hours compared to the total number of hours worked) of
the exercise therapist is 49% lower than the standard productivity of 61%. The VvOCM work
agenda therefore examines how the exercise therapist can optimize daily work processes in
order to spend less time on administrative tasks. The current update of the Reporting Guideline
is intended to promote efficient file management. The optimal use of all digital options (such as
the use of digital questionnaires and the use of Zorgdomein) is also very important.

(Dis)regulate healthcare
The demand for administrative burden reduction is a widely supported position within healthcare and has been
linked to the national action plan to (dis)regulate healthcare. A number of concrete points for improvement
have emerged from this and have been introduced (Stichting (Ont)Regel de Zorg, 2019). For
•
O For physiotherapists, these areas for improvement relate to:
Restriction of mandatory elements in the referral to paramedical care; the absence of
certain elements no longer have consequences for the declarations by the paramedic. Limitation
• of physical checks by health insurers to a maximum of two calendar years after the
acceptance date.
• Removing the prohibition on two paramedical disciplines on the same day
to deal with.
• Removing the obligation to submit the referral, research data and treatment agreement
to be kept in paper form if they can be made available digitally.
• Taking over the debtor risk by health insurers in the first month in which it appears that the
patient is no longer entitled to reimbursement. However, not all health insurers have gone along
with this.

These points for improvement therefore mainly relate to administrative reporting tasks; not on
substantive reporting based on methodical action.

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Explanation of file requirements for methodical action
Clinimetry
Exercise therapists use both quantitative and qualitative diagnostics and analysis, because from
the perspective of exercise therapy, measuring quantity alone is not sufficient to arrive at a
thorough analysis of the problems experienced in relation to the context. Qualitative
diagnostics includes, for example, posture and movement research.

With regard to quantitative diagnostics, the use of measuring instruments is one of the parts of the
professional action of the exercise therapist. Measurements taken by the client can contribute to
diagnosis, assessing (im)possibilities for the client, providing insight into the client experience and
providing insight into the effect of the treatment. Based on the results, the therapist and (if possible)
client can jointly make decisions about the treatment process to be followed. In addition, measuring
instruments are indispensable for mapping the effect of exercise therapy on a broad scale. In line
with this, many exercise therapists already supply data to the LDO (national exercise therapy
database).

With regard to clinimetry, a range of (validated) questionnaires, observations, standardized

(performance) tests and measuring instruments are available in the form of apps that can be used by the
client themselves. The choice of the number and type of measuring instruments to be used depends
of a number of factors (Beurskens et al., 2008).
• The objective of the measuring instrument: diagnostic, prognostic, evaluative.
• The goals of measuring: to increase the client's insight and/or to support one's own
to trade.
• The concept to be measured and the outcome measure that the therapist wants to know.

• The setting (environment, time, user-friendliness) in which information is collected or

measured.

When selecting suitable measuring instruments, the therapist consults the care-related guidelines or
protocols of his or her own professional group or of related professional groups, as well as (current)
professional training courses followed and special professional websites about measuring instruments. A
well-known example iswww.meetinstrumentzorg.nl .

There is no rule for the frequency of measurements (Beurskens et al., 2008). It is evident that in order to
measure the effect of the action, in addition to an initial measurement in the diagnostic phase, new
measurements are taken at least in the final phase. With a longer care process, it seems reasonable to measure
more often to substantiate the progress of the treatment initiated. The decision to measure more often
can be taken based on a number of factors such as:
• The therapist's need to objectify client experience or clinical phenomena
to make decisions (together with the client) about whether or not to continue the treatment plan.
• The therapist's need to increase the client's insight.
• Recommendations in a guideline or protocol.
• The user-friendliness of the measuring instrument.
It is also important to measure for clients with a highly disabling condition who require long-
term care to maintain functions or slow down deterioration, and in particular to look at the
usefulness, value and effect of the therapy.

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Formulate SMART
As stated in Part I - Practice Guideline, the exercise therapist preferably formulates using the
SMART method if applicable.

SMARTstands for Specific, Measurable, Acceptable, Realistic and Time-bound.

Specifically: It is clear what the goal is about and what the intended result is.
Measurable: It is clear when the goal has been achieved or what the result should meet.

Acceptable: The goal is acceptable to those involved. The

Realistic: goal is achievable.
Time constraints: It is clear when the intention is to achieve the goal.

SMARTthinkhelps, but the formulation does not have to strictly follow the SMART. Certainly not if this
leads to a simplification of the representation of what exercise therapists intend with exercise therapy. It
specificis expressed by formulating a goal that is meaningful to the client in concrete terms in relation to
the request for help and the context. Or a goalacceptableandrealistichas already been decided before
the purpose is recorded in the file. Thetimetakes shape in the prognosis for the number of treatments
(possibly over a period of time) and therefore does not have to be included in the goal again. It is up to
the exercise therapist to determine whether the main goal is objectivemeasurablecan be drawn up, or
whether this is only possible at the level of sub-goals.

SOUP/SOAP structure
The SOEP/SOAP structure is originally a medical device and has also been used in paramedical
care for a number of years. However, because the nature of a diagnosis and treatment by a
physician differs from a paramedical treatment, the original meaning of all SOEP/SOAP
domains does not fully apply to exercise therapy.
•
b treatment. The SOEP/SOAP originally stood for: (NHG, 2021; Verenso, 2009)
Subjective: the patient's complaint and request for help and the anamnestic data.
• Objective: the findings from the physical and additional examination.
• Evaluation or Analysis: the working hypotheses and the thinking process, for example a differential diagnosis

•
of the healthcare provider.

Plan: the diagnostic plan or treatment plan and what has been discussed or agreed with the patient.

The SOEP/SOAP is therefore aimed at diagnosing and subsequently setting policy accordingly.
Within an exercise therapy treatment, the client goes through a motor learning process, which
is evaluated and adjusted within each session. It is less appropriate to describe all operations
and their evaluation within the Plan. For this reason, the application of the SOEP/SOAP domains
has been adapted to the exercise therapy setting within the Reporting Guideline for exercise
therapists (see Part I – Practice Guideline).

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Reporting in relation to guidelines and protocols
Guidelines and protocols fall under professional standards, as referred to in the WGBO.

“A guideline is a document with recommendations to support healthcare professionals and

healthcare users, aimed at improving the quality of care, based on systematic summaries of scientific
research and considerations of the advantages and disadvantages of the different healthcare options,
supplemented with the expertise and experiences of healthcare professionals and healthcare
users” (Netherlands Healthcare Institute, 2021)

A directive is not a mandatory requirement. It is a means of indicating which actions are

recommended and under what circumstances. A guideline contains explicit recommendations and
insights, based as much as possible on evidence, that healthcare providers should comply with in
order to provide optimal quality care.
The exercise therapist can deviate from a guideline with substantiated reasons:

• In individual cases, where the exercise therapist decides that following the guideline is appropriate
client is not desired. There may be several reasons for this, for example multimorbidity. In
• case parts of the guideline no longer fit with current events (based on scientific research
offered in professional training or in the literature).

In addition to the care-related guidelines for exercise therapists, guidelines from related
professional groups can also be consulted and followed. If the exercise therapist follows a guideline,
this will be stated in the file.

“A protocol is a document that describes step by step how, with what materials and by
whom an action should be carried out.
A protocol is highly directive and indicates step by step how something should be done (and by whom). This
document should leave little room for interpretation and should therefore be as clear and concrete as
possible.” (NHG, 2015)

If the exercise therapist follows a protocol, the client's file will state which protocol it concerns.
Individual treatment goals must always be formulated in the client's treatment plan. However,
when following a protocol, no time planning and evaluation system (see Part I, Practical
Guideline) need to be added, if these are described in the protocol used.

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Reports
Reporting to the referrer and/or GP must be done in writing after DTO screening and at the end
of the treatment process (VvOCM, 2019; NHG, 2020). The patient can always object to
exchange. It is up to the exercise therapist to weigh this wish against the need for exchange
(NHG, 2020). Other moments for reporting are moments when the exercise therapist deems
this necessary (e.g. in the event of an abnormal course or when the client has a check-up
appointment with the GP/referrer), and/or as agreed within, for example, a platform for
exercise therapists, networks, regional agreements or agreements with referrers.
For long-term treatment processes, it is recommended to send an annual update of the treatment
to the referrer (NHG, 2020).

As mentioned in Part I, the exercise therapist prefers to use the Guideline for Information Exchange between
General Practitioners and Paramedics (HASP Paramedics) when exchanging information with the GP (NHG,
2020). The guideline describes three types of messages for which information can be exchanged
•
d to the paramedic:
The DT message (for exercise therapists the DTO message).
• An Update by a paramedic (an interim evaluation).
• The Final Report.
If Care Domain is used, the exercise therapist already completes the DTO message, the interim
evaluation and the final report in accordance with the format of this guideline. The fields on the
envelope are automatically filled in by Zorgdomein. There is a message for each type
a distinction is made between:

• Envelope (with details of the sender, addressee and relevant client).

• Core (containing the most important current data of the treatment process). File summary
• (in which further explanation can be given of the client's file).
Within theonline viewer of the HASP paramedic and within Healthcare Domain, an explanation is given of
the various input fields.

Multiple treatment processes

A care file is closed after completion of the treatment process. When the client later comes back
for an intake and/or treatment, the file will be reopened.
Administrative data will be adjusted where necessary.
If the client comes because of the same condition or complaints, the data about methodical action
will be adjusted based on current events, such as: reason for coming, request for help, additional or
current research data, exercise therapy diagnosis, treatment goals and plan. If the client comes
because of another complaint or condition, a new treatment process will be started.

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Relevant legislation and regulations
•
The following legislation and regulations influence exercise therapy and o efentherapeutic
reporting:
Medical Treatment Agreement Act (WGBO)
• General Data Protection Regulation (GDPR)
• Domestic violence and child abuse reporting code + assessment framework

• Individual Healthcare Professions Act (BIG)

• Use of Citizen Service Number in Healthcare Act (Wbsn-z)

• Healthcare Quality, Complaints and Disputes Act (Wkkgz).

Medical Treatment Agreement Act (WGBO)

The WGBO (part of Book 7 of the Civil Code) provides rules for the care relationship between an
individual client and the care provider. The WGBO provides, among other things, rules for the file,
the right of inspection, the obligation to provide information, consent for treatment and
professional secrecy. Based on the WGBO, the care provider is obliged to observe the care required
to provide good care. Good care means that one acts in accordance with professional standards,
according to recent insights from medical science, with due regard for the rights of the client.

•
The WGBO has consequences for the exercise therapy reporting as it requires the exercise therapist to d e
imposes the following obligations:

• Consent requirement, including consent for minors

Information obligation

• File obligation
• Right of access (of the patient)
• Retention obligation (this has recently been extended from 15 to 20 years)

• Right to destruction (a right of the patient)

• Duty of confidentiality.
Information obligation

The exercise therapist provides the patient with the information he needs to make responsible
decisions about his health. This means that the exercise therapist treats the patient
•
d should clearly inform about:
The nature and purpose of the examination or treatment.
• The exercise therapy diagnosis.
• The treatment plan.

• The expected risk to health.

• The option to refrain from treatment.
• Possible alternatives (other examinations and treatments by other care providers). The
• prognosis, implementation period of the treatment and its expected duration.
In a supplement to the WGBO as of January 1, 2020, the emphasis is on 'making decisions together'. The
exercise therapist is obliged to consult with the patient in a timely manner and the patient is also invited
to ask questions. The exercise therapist does not have to note in the file that the information obligation
has been met.

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There are two exceptions to the information obligation:
1) When the exercise therapist is of the opinion that providing information would seriously harm
the patient.
2) When the patient indicates that he does not want to receive information.

At the patient's request, the exercise therapist must inform him or her in writing.
The exercise therapist tailors the dosage and timing of the information provided to the patient's
personal situation.

If a patient under the age of 12 is treated, the exercise therapist has the obligation to provide
both parents with information upon request, whether the parent in question has parental
authority or not. For children aged 12 to 15, the child's consent is required to provide the
parent(s)/guardian with information (or to inspect the file). This is only different if the parent
needs information to give permission for treatment (see consent requirement). The patient has
the obligation to provide information to the exercise therapist about matters relating to the
implementation of the treatment. The exercise therapist asks for this information in the
anamnesis, because the patient cannot be expected to know what information is involved.

Consent requirement
For every exercise therapy treatment, the patient's consent is required before starting or continuing
the treatment. The exercise therapist must inform the patient (see obligation to provide
information) in such a way that the patient is able to make an informed decision. For non-invasive
actions, consent may be assumed to have been given. However, it is important that the exercise
therapist ensures that the patient agrees to the examination, the treatment and the follow-up.

The therapist verifies and notes whether the client has understood the information and agrees with the
treatment plan. For children <12 years of age, the consent of one or both parents/guardians (authorities)
is required. For children aged 12 to 15, permission from parent(s)/guardian(s) and the young person is
required. (It is sufficient to note in the file that permission has been given; the name of the parent in
question does not have to be recorded). From the age of 16, young people have an independent right to
information. They must give permission themselves. Professional secrecy also applies to their
representatives.

File obligation
The exercise therapist is obliged to keep a file with information about the patient. WGBO article
7-454:“The care provider sets up a file regarding the patient's treatment. He keeps notes of the
information regarding the patient's health and the procedures carried out in that regard and
includes other documents containing such information (X-ray, letters from other care providers,
etc.), insofar as this is necessary for proper assistance to the patient. is necessary for him”.

In addition to the substantive requirements for this file management, the readability, completeness,
conciseness, reliability and transparency of the data are also of great importance. An easily readable
file is of great importance for an observer or trainee. This also means that it

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23
file is at the same time complete and concise. Concise formulation is very important for efficient
file management. At the same time, this should not lead to the use of abbreviations that
undermine readability.
In terms of reliability, the reporting must be in accordance with reality and must not give rise to
doubt about what is meant.

Right of access
The patient has the right to inspect his file. This concerns a direct right to inspect and copy without the
intervention of third parties. The patient is in principle allowed to view everything that has been written about
him: only when the privacy of someone else is at stake or the information poses a danger to the patient
himself, is the care provider is not obliged to provide access to the file. As mentioned in the obligation to
provide information, permission from the child is required for children aged 12 to 16 if the parent/guardian
wants to view the file.
Parents are not entitled to inspect the medical file of children >16 years of age, unless the child
gives permission. A request for access must be processed as quickly as possible, in any case
within one month. A reasonable reimbursement of expenses may be requested for the copies.
Personal work notes that are not intended for third parties, including the patient, should be
kept separately from the file.
Since January 1, 2020, the WGBO also gives surviving relatives a legal right to inspect the file of
a deceased patient. Circumstances under which surviving relatives can inspect
•
k stringing:

When the patient has given permission for this while he is alive.
• When, pursuant to the Healthcare Quality, Complaints and Disputes Act (Wkkgz), a notification of
an incident has been received.
• 'For everyone' on the basis of a compelling interest.
• A special arrangement for access applies to the parents and guardian of a deceased child <16.
Retention obligation

As of January 1, 2020, the legal retention period of the file has been extended from 15 years to
20 years. All files completed before 2020 must now be kept for 20 years. The 20 years are
counted from the moment the last note is recorded in the file (usually at the end of the
treatment). The retention period also applies in the event of the patient's death. Sometimes a
file can be kept for longer than 20 years, for example in the case of hereditary conditions or
chronic diseases. For minors, the retention period only starts when they reach the age of
majority (>18).

Retention obligation when stopping a practice

The same period of 20 years applies in the event of termination of a practice or death. During a
practice transfer, all files are taken over, including those of patients whose therapy has been
completed. However, in the context of the GDPR, permission for this must be requested from
each patient. This may also be done through an objection system: patients can be informed (by
email or letter) about the intended practice transfer, with the opportunity to object to the
transfer of the file within a reasonable period (e.g. 4 weeks). Without a response within this
period, the files can be transferred to the practice successor (KNMG, 2021; VvAA, 2019).

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If permission is given and the selling exercise therapist transfers files to a successor, it is
important to make proper agreements about this in the form of a processing agreement. The
agreements relate to access to the medical data if a complaint or claim for damages is
submitted at any time, the retention period, security measures, etc.

Another option is for the selling party to keep the medical records of clients whose therapy has
already ended. If these are digital files, agreements can be made with the software supplier. If
a complaint or claim for damages is submitted at any time, the medical data will still be
available. Former clients do not need to be informed and no further agreements need to be
made regarding the storage of these medical records.

Destruction
The patient can request the exercise therapist to destroy (part of) his file. This request must be
complied with within three months. The law requires that the data must be destroyed at least
after 20 years. In special situations (for example patients with a hereditary condition) this
obligation is waived.

Duty of confidentiality
Paramedical and medical data are privacy-sensitive and the care provider must handle this with
the utmost care. Only authorized persons (the treating exercise therapist, observer or trainee)
may view the data. Only if the patient gives explicit permission, others than those mentioned
above may view the file. It is advisable to request this permission in writing in connection with
possible evidence in the event of a dispute.

Medical confidentiality may only be broken in a limited number of cases: with specific consent
from the patient or when this is required by a legal provision (WGBO art. 7.457). Since January
1, 2006, the healthcare provider is obliged under the Healthcare Insurance Act to provide
(medical) information to the health insurer. The legal guarantees are: all persons working for
the health insurer are obliged to maintain the confidentiality of the data. When it comes to
testing the effectiveness of the treatment, in practice anonymized files are made available to
health insurers.
The obligation of confidentiality does not apply to other care providers who are directly
involved in the treatment or guidance of the patient. It is nevertheless recommended to inform
the patient that information will be provided to fellow practitioners. The latter may only be
informed to the extent that this is a necessary part of their treatment.

Information may also be provided to the person who, as the patient's representative, must give
permission for the treatment(WGBO art.7.457). This could be the curator or mentor, a written
representative of the patient, the spouse, registered partner or other life companion, a parent,
child, brother or sister.(WBGO art. 7,465).
Under certain conditions stated in the WGBO, a healthcare professional may provide information for
the purpose of statistics or scientific research in the field of public health without the patient's
consent.(WGBO art. 7,458). A healthcare professional may breach her professional secrecy if she
experiences a conflict of duties (KNMG Implementation of the WGBO, 2004). Consider reporting to
Safe at Home if you suspect domestic violence and/or child abuse.

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Chain care
Chain care involves a sequence of different types of care that various healthcare providers offer
to a client suffering from a specific condition. Multiple treatment agreements may arise. From a
legal perspective, a care provider in such a situation would again have to ask the client for
explicit permission to provide data. However: a healthcare professional who, in the context of
chain care
wants or needs to provide data to a subsequent healthcare provider, it may be assumed that the client
•
h has given permission under the following conditions (KNMG, 2004):
The patient must be well informed in advance about the scope of the chain and about the
care providers who must have access to his data when this is necessary for
good treatment or care.
• It must concern concrete situations.
• It must be clear to the patient that data is provided for healthcare purposes.
• The patient did not object.
• The provision of data is limited to data that is necessary for the recipient.

NB: the client must give explicit permission for providing data to another care provider in
connection with a new request for help outside the chain (Paans, 2020).

General Data Protection Regulation (GDPR)

The GDPR is the privacy law that replaces the Personal Data Protection Act (WBP) as of
5/25/2018 and applies throughout the European Union. Thanks to the GDPR, the protection of
personal data is regulated in the same way in all EU countries and the same rules apply in all
Member States. You need a legal basis for collecting personal data. The exercise therapist can
rely on the fact that:
“the data processing is necessary for the execution of a (treatment) agreement”. What is
important in the GDPR is that security when processing personal data is better guaranteed.
Processing includes obtaining, collecting, requesting, consulting and changing data. The
processor must take the regulations of the GDPR into account throughout the entire process.
The GDPR applies to almost all data processing that can be traced back to patients or clients.
This applies to both electronic and manual processing.

Accountability
The GDPR places more responsibility on the healthcare provider/care provider to demonstrate
that the privacy rules are complied with. Compliance with accountability ensures an important
contribution to the protection of individuals' fundamental right to privacy. This accountability
means that the healthcare provider must be able to demonstrate how the data processing
complies with the GDPR rules and why certain choices have been made.

Security duty
Exercise therapists must take appropriate technical and organizational measures to protect
personal data against loss or any form of unlawful processing. In this context, appropriate
means that the security corresponds to the state of the art. The security obligation is broadly
formulated in the GDPR. For concrete requirements, healthcare providers can connect with
existing standards for information security in healthcare (NEN7510,

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26
7512 and 7513). In healthcare, 'ZorgMail', 'Zorgdomein' and 'Zivver' are often used when
sending electronic messages between healthcare providers. Exchange of personal data via an
unsecured email program is not recommended.
Data may only be provided to third parties, other than co-practitioners, after the client has given
permission.

Overlap WGBO
There is a certain overlap with the WGBO. The WGBO is mainly aimed at strengthening the position
of the patient (patient rights); the GDPR guarantees privacy regarding the recording and provision
of personal data (privacy rights).
Pursuant to the GDPR, the patient must be informed about the manner in which the processing
takes place. It must also be clear who is responsible. The patient must also be made aware of the
•
r facts on which he can rely. The patient has, among other things:
Right to data portability; the right to transfer personal data.
• Right to be forgotten; the right to be 'forgotten'.
• Right of access; the right to view the personal data processed by the therapist. Right to
• rectification and addition; the right to have personal data processed
modify.
• The right to limit processing; the right to have less data processed.
• Copy and destruction of data (fees may apply). The right regarding automated decision-
• making and profiling; the right to one
human perspective on decisions.

• Right to object to data processing.

• Right to information.
• Right to privacy and protection of privacy.
• Right to treatment in accordance with scientific standards.
• Right to refuse or stop treatment.
• Right to free choice of care provider.
• Right to file a complaint.
Domestic violence and child abuse reporting code and assessment framework
Since July 1, 2013, exercise therapists have been legally obliged to have a reporting code with
which they can take action against domestic violence and child abuse.
This means that all organizations and independent professionals are expected to know the reporting code and
to act accordingly. In this context, the VvOCM has drawn up the 'Reporting Code for Exercise Therapists for
Domestic Violence and Child Abuse' with a step-by-step plan. In the context of the tightening of this law in
2017, the VvOCM worked together with the PPN partners and the KNGF in 2018 on an assessment framework
that can be seen as a supplement to the already existing step-by-step plan (Kroezen-Brenkman, 2018). This
reporting code is explained in the Rationale of November 2018 (Dalen, 2018). From January 2019, exercise
therapists are obliged to act in accordance with the amended reporting code.

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For the purpose of reporting in step 1 'identifying signals', the reporting code describes:

'The exercise therapist describes the signals as factually as possible and distinguishes between
established facts and suspicions. He makes a follow-up note. When recording information from third
parties, the exercise therapist states the source. Diagnoses are only recorded if they have been made by
a competent professional.
The documents/forms regarding a report must be kept in the file.

More information about the reporting code and the step-by-step plan with assessment framework can be found on the
VvOCM website (VvOCM, 2021).

Individual Healthcare Professions Act (BIG)

The BIG Act provides rules for actions in the field of individual healthcare. Individual healthcare
includes all healthcare activities performed in connection with the health of an individual
person, including conducting research and providing advice. The BIG Act focuses mainly on the
quality of the individual healthcare professional.

The BIG Act is a framework law: specific parts are regulated by a General Administrative Order.
By Order in Council of 18 June 2008, the description of the exercise therapist's area of
expertise was amended (Article 21) with a view to the introduction of direct accessibility as of 1
July 2008. Independently making a diagnosis and recognizing the need to treat the patient
Referring to a doctor is legally established here as part of the exercise therapist's area of
expertise.

Use of Citizen Service Number in Healthcare Act (Wbsn-z)

Under the Citizen Service Number General Provisions Act (Wabb), government bodies can use
the BSN for their activities. Because the healthcare sector also uses a unique personal number,
a separate law has been created: the Use of Citizen Service Number in Healthcare Act (Wbsn-z).
A unique personal number is very important in healthcare to determine which data belongs to
which client. In this way, the quality of mutual communication and ultimately the quality of care
can be improved. The number is also needed to simplify declaration traffic and provide better
protection against identity fraud. Based on the combination of the Unique Healthcare Provider
Identification (UZI) and the BSN, the most current address details and systems of insurers from
the Municipal Personal Records Database (GBA), for example, can be used to determine the
insurance eligibility of patients. Healthcare providers and institutions are obliged to work with
BSNs that have been verified.

e Wbsn-z obliges healthcare providers to:

•
D In all communications, both digital and on paper, between healthcare providers and between them
healthcare providers and health insurers to use the patient's BSN.
• Use the patient's BSN to ensure that the processing of the
personal data relates to the patient.
• To establish the patient's identity with a legal identification document
shown upon first contact with the healthcare provider.
• Register the patient's BSN in the administration when providing care to the patient.

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Healthcare Quality, Complaints and Disputes Act (Wkkgz)
The Quality, Complaints and Disputes Management Act (Wkkgz) obliges healthcare providers to
have an accessible and effective complaints handling system and to pay attention to patient safety.
Important elements of good and safe care are having implemented a safe incident reporting system
(VIM), an extension of the reporting obligation and tackling complaints and disputes from clients
better and faster. Under this law, all healthcare institutions and individual healthcare providers are
obliged to have implemented a procedure for reporting incidents; the VvOCM has made tools and
information available on its website regarding safe incident reporting. In addition, healthcare
providers must be affiliated with an approved complaints and disputes procedure. Exercise
therapists can join theComplaints and dispute settlement procedure for paramedics (exercise
therapists who are members of the VvOCM are automatically affiliated with this). Non-members of
the VvOCM can register for this via the VvOCM. Healthcare providers, including exercise therapists,
are obliged to inform clients of the possibility to file a complaint and where they can do so: viawww.
complaintsloketparamedici.nl . The decision of a dispute resolution body is binding for both the
complainant and the healthcare provider. Another important element of this law is the so-called
obligation to ensure. Exercise therapists who either employ a colleague or bring a colleague into
practice for a short or longer period must ensure that the colleague meets the applicable quality
requirements and standards. This can be done, for example, by obtaining information from previous
employers or clients.

Reporting incidents
Part of the Wkkgz is also that healthcare providers can safely report an incident.
In the context of reporting incidents, exercise therapists must include information about
incidents that have led or could lead to harm to the patient in the file. This concerns all data
that are necessary for proper assistance to the patient. For primary care therapists: see
brochure'self-evident safety'(VWS, 2010) and the reporting form'Safe Incident Reporting'on the
VvOCM website.
Inpatient care uses forms to report incidents. In nursing homes and care homes, the MIC form
must be completed (Client Incident Reporting, (Arcares, 2002)). The VIM method (Safe Incident
Reporting) is applied in hospitals.

Consulted sources
1. Legislation and regulations in healthcare (2nd edition), Nictiz, May 2013

2. Legal analysis of electronic data exchange in healthcare, National Government, June 2013
3. Government,laws.overheid.nl
4. Nictiz,www.nictiz.nl
5. VZVZ (Association of Healthcare Providers for Healthcare Communication),www.vzvz.nl
6. Dutch Data Protection Authority,www.autoriteitpersoonsgegevens.nl/

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Abbreviations

AGB General Data Management code

AGM General Members Meeting
GDPR General Data Protection Regulation Citizen
BSN Service Number
DCSPH Diagnosis code according to the diagnosis coding system for paramedical
DTO assistance Direct Accessibility Exercise therapy
EBP Evidence Based Practice Dutch Society
NHG of General Practitioners
ICF International Classification of Functioning, Disability and Health Royal
KNMG Dutch Society for the Promotion of Medicine Netherlands Institute for
LEVEL Healthcare Research Netherlands Paramedical Institute
NPI
ODIM Exercise Therapy Diagnostics and Intervention Model
PPN Paramedical Platform Netherlands
RPS Rehabilitation Problem Solving form
S.K.F Stichting Keurmerk Physiotherapy
VvOCM Association of Exercise Therapists Cesar and Mensendieck
VWS Ministry of Health, Welfare and Sport Unique Healthcare
UZI Provider Identification
UZOVI Unique Health Insurer Identification
BIG Act Individual Healthcare Professions Act Act on the use
Wbsn-z of citizen service numbers in healthcare
WGBO World Health Organization Medical Treatment
WHO Agreement Act
Wkkgz Healthcare Quality, Complaints and Disputes Act
ZN Health Insurers Netherlands

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References

Arcares. (2002).Reporting Incidents Clients In nursing and care homes.

Bastiaansen-ten Haaf, C., Smorenburg, N. (2015). The Exercise Therapy Diagnostics and
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Beurskens et al. (2008).Measuring in practice, step-by-step plan for the use of measuring instruments in
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KNMG. (2004).Implementation of the WGBO Part 4 - Access to patient data. Implementation of the
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KNMG. (2021).Handling medical data.www.knmg.nl

NHG. (2020). Guideline for Information Exchange between Doctors and Paramedics (HASP Paramedic Guideline).

NHG. (2021). Medically given SOEP report | HIS Reference Model.https://referencemodel.nhg.

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Paans, W. (2020). Nursing and Caregiver Reporting Guideline.

Rijksoverheid.nl. (2019). Administrative agreements for paramedical care 2019-2022.https://www.

government.nl/documents/kamerstuks/2019/06/20/kamerbrief- bestuurlijke-
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Foundation (De)Regel de Zorg. (2019).(De) Arrange the Paramedic - Proceeds from scrapping sessions.
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Verenso. (2009). Medical Reporting Note File management by the geriatric

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Vreeken, H. et al. (n.d.).KNGF guidelines methodology 2022.www.kngf.nl

VvAA. (2019). Privacy rules do not prevent the transfer of patient files.https://www.vvaa.nl/voor-
leden/nieuws/europese-privacy Rules-stan-transfer-patientendossiers-niet-in-de-weg VvOCM.
(2019). Professional profile Exercise therapist. Retrieved fromwww.vvocm.nl

VvOCM. (2020).STRATEGIC POLICY PLAN 2021-2023.https://vvocm.nl/Portals/2/VvOCM

Strategic policy plan 2021-2023 final.pdf

VvOCM. (2021). Reporting code HG & KMH.https://www.vvocm.nl/Praktijkvoering/Meldcode-HG-KMH

VvOCM and KNGF. (2006).Red Flag Course Direct Accessibility Exercise Therapy.

VWS. (2010). Self-evident Safety (Brochure).

Healthcare Institute of the Netherlands. (2021). AQUA Guidelines.

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T(030) 262 56 [email protected]