Off-the-job self-care tips include : ○ Sacred ritual practice. ○ Physical exercise. ○ Regular massage for yourself. ○ Participation in sports and games. ○ Vacations. ○ Time spent with friends and family (AMTA, 2021b) . Documentation and records Proper documentation and record keeping is a critical, routine aspect of a successful practice. Massage therapists or other staff members should keep notes legible and accurate. If therapists or other professionals refer to files at some time in the future (a medical emergency or legal proceedings, for example), the context and details of the notes should be clear. Other healthcare personnel will need to know the background, presenting status, actions taken, and the results, with some discussion of treatment strategies and expected objectives (Thompson, 2018). Therapists should adhere to the following guidelines for preparing and maintaining records (Thompson, 2018): ● Maintain accurate and truthful records: Record only factual information, observations, and actions. Don’t record opinions or conjecture about a client’s condition. When recording statements made by a client (regarding an injury, for example), therapists should use quotation marks to demarcate the client’s words. Therapists should keep a separate file for personal notes or any material of a speculative nature. ● Make sure the forms they use to collect client information are appropriate for their practice and cover all pertinent areas. Therapists should also ensure forms are free of errors and are easy to read and understand. Questions should be stated simply. Therapists should avoid jargon or complicated medical terminology, or define terms as needed. In addition, they should review forms on a regular basis, and revise or simplify confusing formatting or content. ● Take a comprehensive case history and review it with the client before beginning treatment. This should include an overview of the client’s general state of health and thorough medical history, the reason(s) for seeking massage therapy, onset and duration of problematic symptoms, medical history of family members (if appropriate), and occupational background. ● Ensure staff members are trained to record client histories and other important information properly and thoroughly, and to ask appropriate follow-up questions if there is any ambiguity in a response. Therapists or organizations should implement some structure or mechanism to ensure this information is complete for every client and answers are recorded in sufficient detail. Therapists should review any personal or medical information taken by other staff members in a personal interview with the client to ensure information was recorded properly and in adequate detail. ● Areas that do not apply to a specific client should be marked “N/A” (nonapplicable) rather than left blank. ● Develop a short, simple form that clients can use to note their progress (or lack of progress) at each visit. ● Document any client noncompliance with their care plan, including canceled appointments (DNKA = did not keep appointment), refusal or failure to follow healthcare instructions and/or take needed medication, and activities or behaviors that pose a risk to the client’s health. Therapists should communicate the rationale for their opinion and should not proceed with any action that conflicts with their professional judgment. ● Have clients sign a form acknowledging they have been informed of the potential consequences of their action
or inaction and are choosing to refuse recommended treatment, if clients disregard recommendations for treatment. ● Notes should be legible and accurate. Therapists should pay attention to their handwriting and use clearly written and recognized abbreviations. They must remember that they and other people may need to refer to these notes years in the future, so they should be easy to read and understand. ● File records promptly and accurately. Establish a strict filing system and adhere to it, and be sure other staff members know the system and the importance of using it. The following guidelines were established for litigation purposes and should be standard practice in all healthcare environments (Thompson, 2018): ● Practitioners should alter records as minimally as possible, and only when necessary. ● Practitioners should not erase or otherwise correct errors. In regard to written records, they should cross out an error using a single line, so as not to conceal what is written underneath, and write the word “error” above the incorrect statement. The correction should also be marked with a date. ● If practitioners review their records and feel they need to clarify a point, they should write the date and the additional comments with the note (labeled “addendum”). ● If litigation is threatened, practitioners should not make any kind of change to the records. Not all file contents are subject to the same retention times. Massage therapists should keep records for current and former clients for as long a period as is practically possible, but at least the length of time specified by federal and state regulations as the legal minimum. They should retain children’s records after they turn 18 for a length of time that equals the state’s statute of limitations. In many states, a therapist is required to keep records for seven years after a client’s last treatment, though in some cases, such as in the state of Washington, the requirement is as little as three years (Thompson, 2018). Documenting emergencies Emergencies require immediate response, which includes detailed documentation. All facilities must have detailed emergency response plans, which may include identifying a staff member who will have the responsibility to document the emergency and response procedures. The responder verbally reports to the recorder the condition of the client, what emergency procedures are being taken, the outcome of the response, and the condition of the client, on an ongoing basis (Armstrong, 2012). The recorder should have an accurate time piece to refer to during the emergency to assist them in record keeping. During this stressful time, it is important that the selected recorder stays calm and focused to accurately document the event. The following components should be included in the timed documentation (Armstrong, 2012): ● What was the client’s condition prior to the emergency? ● What was the client’s condition when the emergency began? ● When did the emergency occur?
● What was the nature of the emergency? ● What signs and symptoms were identified? ● When did intervention begin? ● When were emergency personnel notified? ● When was the family or caregiver notified? ● What interventions were provided? ● How did the client respond?
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Book Code: MFL1227
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