Evaluation of the Patient
Equivalent evaluation standards should be established for patients whether the physician is using conventional medical practices or CAM. Prior to offering any recommendations for conventional and/or CAM treatments, the physician shall conduct an appropriate medical history and physical examination of the patient as well as an appropriate review of the patient’s medical records. This evaluation shall include, but not be limited to, conventional methods of diagnosis and may include other methods of diagnosis as long as the methodology utilized for diagnosis is safe and reliable, and shall be documented in the patient’s medical record. The medical record should also document:
• whether other, including conventional, medical options have been discussed, offered or tried, and if so, to what effect, or a statement as to whether or not certain options have been refused by the patient or guardian; that proper referral has been offered for appropriate treatment;
• that the risk and benefits of all therapeutic options to the extent known have been appropriately discussed with the patient or guardian;
• that the physician has determined the extent to which the treatment could interfere with any other recommended or ongoing treatment.