long as it contains professional insight that may be open for review. ● Put statements by clients in quotation marks. ● Make sure all required forms are completed and updated as required. ● Use only professional language, and universally understood abbreviations; avoid slang or jargon. ● Complete a case history and discuss it with the client prior to beginning treatment. Include effects of the current problem on daily living, recreational or occupational functioning. ● Complete a comprehensive medical history, reason for seeking services and current symptoms. ● Train staff in proper record-keeping and methods of documentation. Review information completed by staff to ensure accuracy. ● Mark forms with “N/A” in spaces that do not apply. ● Record any issues, conflicts, cancellations, or non-compliance that impedes progress. ● Document evidence that indicates a risk to client health or well-being (see mandated reporter section), and note 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. The recorder should have an accurate time piece to refer too 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: ● 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? Session documentation It is critical to document every interaction with clients at the end of each session. This documentation provides evidence of competent and ethical practice and protects the practitioner from allegations of negligence, malpractice or ethics violations. Some guidelines for charting are as follows: ● What was the nature of the emergency? ● What signs and symptoms were identified? ● When did intervention begin? ● Chart date and time, a summary of massage modalities used, duration of hands-on treatment, as well as the position(s) of the client. Record any other relevant details, too, including what lotions or oils were used, if hot stones were placed on the client, anything other significant information. ● Chart the status and changes in the level of pain experienced by the patient before and after receiving massage, if this information is relevant. ● Chart any assignment of treatment tasks to other personnel, including staff members involved, introduction to client and instructions given. ● Chart any communication other health care professionals involved in a client’s treatment. Include each time a call is made to health care provider, even attempts at contact, recording the exact date and time. Chart the details of the message and the healthcare provider’s response. ● Read a verbal order back to the provider after charting it and read the name on the chart to confirm client identity. ● Follow up conversations about changes to a client’s treatment plan with a letter to the provider detailing the agreed upon changes. ● Record all telephone conversations with the client, always noting the date and time.
action(s) to address issue(s) following follows ethical standards and professional judgment. ● When an issue arises that may be cause for termination of services, i.e., one that cannot be resolved with the client, have clients sign a document acknowledging that they have been informed of the potential consequences of their actions that are counter to the treatment plan or effective therapeutic outcome. This may include refusing treatment, engaging in unsafe practices, lack of follow-through with the treatment plan, or other non-compliance. ● Make sure that files, including electric systems, are secure and cannot be accessed by unauthorized personnel. ● Do not alter files using erasures or correction fluid. A single line can be drawn through the error and changes should be made at the time, dated, initialed and noted as an error. If additional material needs to be added, it should be recorded as an addendum and signed and dated. ● In cases of litigation, at no time should records be altered. ● Be sure to maintain records in accordance with state or federal timelines. ● When were emergency personnel notified? ● When was the family or caregiver notified? ● What interventions were provided? How did the client respond? (Armstrong, 2012) Documentation should be clear, concise, accurate, and complete based on observable evidence not opinion or conjecture. Remember that any documentation could be viewed in an ethics or legal investigation and may become public information. It is important to remember that in a court of law proper documentation can be the defense against a charge of negligence and/or malpractice. The courts will not consider documentation that was reconstructed in the same way as documentation that clearly provides the time frame of actual events. The recorder and responder should review, sign and date the document and be sure it is accurate and complete. Nothing should be blacked out or covered with correction fluid but a line or word may be corrected and initialed as long as the original words can be seen. ● Keep client records confidential. ● Check that the correct client’s file is accessed before writing and make sure each client record page has the client’s name and the date on it. ● Chart an action at the time it is performed because contemporaneous notes are the most credible. ● Write late entries that are essential to the client’s health and on-going treatment. Always make a notation of “late entry” after for this documentation, along with the actual date and time of the late entry. ● Correct any mistakes in a client’s file according to the policies and procedures put in place by the employer. Never alter notes by anyone else ● Record current health conditions, medications and therapies being used, lifestyle factors, prior experience with massage, as well current reasons for receiving massage. ● Write legibly and in ink when doing handwritten files. ● Write concise, clear notes reflecting facts. ● Use correct medical terminology and describe exact anatomy, physiological responses or specific techniques of massage and bodywork. ● Use abbreviations or initials that have been approved for use by the employer and be sure that everyone in the practice is aware of the approved abbreviation list and understands the exact meaning of each approved abbreviation. ● Chart solutions as well as problems. ● Document only your own observations: what you see, hear and feel.
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