● Practitioner’s area(s) of expertise, philosophy, and/or approach to massage. ● Fees and service schedule. ● Payment terms. ● Filing procedures for written complaints. ● A right to information statement, asserting the client’s right to the following information: 1. Practitioner’s assessment of the client’s physical condition. 2. Recommended treatment, estimated duration of treatment, and expected results. 3. Copy of client’s health forms/records held by practitioner: ▪ Statement of confidentiality. ▪ Statement of refusal, explaining the client’s right to terminate a course of treatment at any time, and to choose a new practitioner. ▪ Clients’ right to invoke, explaining client’s right to invoke these rights without fear of reprisal. Both the practitioner and client are ensured the “right of refusal.” For a client, this means the right to refuse, modify, or terminate treatment regardless of any prior agreements or statements of consent. For a practitioner, this means the right to refuse to treat any person or condition for just and reasonable cause. These rights safeguard a client’s freedom to choose any practitioner, and a practitioner’s freedom to terminate treatment, if necessary. These rights might come into play in cases of negligence or abuse. For example, practitioners can refuse to work with an abusive or unstable client, and clients can refuse treatment from a practitioner they suspect is practicing under the influence of alcohol, drugs, or any illegal substances. status, consent forms, and guardianship information, if applicable, may be recorded. 6. Signed release of information allowing for communication between health provider and primary care provider if applicable. 7. Past medical history including any medication that could be contraindicated. 8. Social history, including but not limited to, tobacco and alcohol use, and/or substance abuse for ages 12 and older. 9. Allergies and any adverse reactions in a uniform location of the record, or notation of no known allergy (NKA) or no known drug allergy (NKDA), if applicable. 10. History or other data for the presenting complaint, including conditions affecting the patient’s health status. 11. Diagnosis documented for each patient visit. 12. Treatment/follow-up plan and patient discharge instructions. 13. Preventive health services reviewed and documented. 14. Assessment results. 15. Coordination of care between providers to include referrals, with evidence of provider review and treatment plan integration of consultation, therapy, and other reports, if applicable. It is important that documentation of all sessions be recorded and protected to ensure confidentiality and to provide data on assessment, treatment plan protocols, progress notes and any other relevant information obtained during a session. It is important that these documents must be accurate and thorough in case a malpractice or ethical complaint is filed against the therapist. Remember, anything in the file can be read in a court of law. The following guidelines should be followed when recording data and maintaining client records in addition to the standards listed above: ● All information must be accurate, free from error, and based on measurable data and direct observation. ● Records should be organized and legible. ● Avoid conjecture, speculation, opinions or other subjective data. A separate personal note file can be maintained as
monitor the quality of care it delivers and to carry out quality improvement activities for the benefit of all clients (Quizlet, 2016). Informed consent should: ● Inform the patient regarding the recommended treatment or procedure, including: 1. The name, nature, and details of the recommended treatment or procedure. 2. Indications for the recommended course of action. 3. Likelihood of success of the recommended treatment or procedure for this patient. Clients should fill out a formal intake form on their first visit that includes: 1. Client’s name, address, and telephone or other contact number(s). 4. Insurance/payment methods. 5. Emergency contact information. The client should also sign and date the following statements: 1. Release of medical records. 2. Notice of informed consent, with scope and limitations of practice. 3. Client’s bill of rights. A client’s bill of rights typically includes the following information: ● Name of practitioner. ● Details of practitioner certification and list of credentials. 2. Reason for visit. 3. Medical history. Proper documentation and record keeping is a critical aspect of a successful practice and therapists should keep legible and accurate notes. If therapists or other professionals refer to files at some time in the future, for a medical emergency or legal proceeding, the context and details of the notes needs to 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. Medical massage therapists should adhere to the requirements of their state and federal laws, including the Health Insurance Portability and Accountability Act (HIPAA) (HHS, 2016b). The following are general guidelines for preparing and maintaining records: A. Confidentiality and Security Standards: 1. Treated as confidential information. 2. Stored in a centralized secure location accessible only to authorized personnel who are periodically provided training for confidentiality and security of patient information. 3. Retrievable in a timely manner by office staff and practitioners. 4. Confidential information is released only in accordance with applicable state and federal laws. 5. Appropriate safeguards are in place to protect the B. Minimum Documentation Standards: 1. Records must be legible, accurate, current, detailed, and organized to permit effective and confidential patient care and quality review. 2. Each chart entry must be dated. 3. Each chart entry must have author identification, and title with a legible signature and co-signature (if applicable). 4. Two forms of patient identification information must be noted on each printed page, i.e., name and date of birth (DOB). 5. Personal biographical data, DOB, sex, race/ethnicity, confidentiality of the record, in compliance with applicable state and federal laws, including HIPAA.
DOCUMENTATION AND RECORDS MAINTENANCE
mailing/residential address, employer, telephone number(s), emergency contact information, marital
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Book Code: MTX1323
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