● Write frequently and to demonstrate ongoing care. ● Follow standards for compliance with the state practice act, facility policy, professional organizational guidelines, and/or reimbursement source, and HIPAA requirements. ● Chart response of a client, including verbal feedback, and nonverbal responses such as changes in breathing or body positioning. ● Chart precautions and preventive measures such as cautions for massage based on physical or mental conditions, specific areas of concern or areas needing massage. Include the explanations given to the client concerning these issues and make sure they are included in the informed consent forms signed by the client and practitioner. ● Chart the errors and how they were handled on the appropriate incident form. ● Chart and report client refusals according to facility and state regulations. ● Chart your client teaching efforts and discussions to help inform clients if these components are within the scope of practice. ● Chart any recommendations made to the client. Be sure not to make any recommendations that can be construed as medical diagnosis or advice. ● Never chart judgments, opinions or interpretations, only facts as observed ● Do not alter a record, as this is illegal.
● Do not write about administrative problems or make excuses for practice issues. Instead, state why the intervention was not performed and what was done to solve the issue. Chart objective information describing the facts of the incident and actions taken. ● Write specific, accurate descriptions rather than sentence fragments. Do not use vague expressions, such as “appears” or “seems.” ● Do not write prejudicial, judgmental or sarcastic statements. Legally credible documentation is a contemporaneous, accurate record of the care the client received and the competence of the practitioner. Client files should tell anyone who reads them that the practitioner provided competent and ethical care. ● Charting should show compliance with policies and procedures of the employer or agency. Following and documenting according to policy and procedure provides a safety zone that may protect against a malpractice lawsuit. (Armstrong, 2012) Establishing, following and charting compliance with concrete, specific standards for providing quality care and interaction with clients, families and staff is the foundation for ethical, professional practice. Structures and controls of the practice chain of command outline the responsibilities and expectations of all personnel. Timely, accurate and uniform documentation procedures are a critical part of control procedures that protect all personnel, the practice, and most importantly, the client. not be communicated to a third party, even one involved in the patient’s care, without the client’s written consent or a court order. Practitioners must treat clients with respect and dignity. They should handle personal information with sensitivity, and keep the content of written records a private matter. Practitioners who do not or cannot resist telling secrets or repeating gossip in their personal lives should be aware of the heavy penalties associated with jeopardizing client confidentiality in a professional context. Without the understanding that their disclosures will be kept secret, clients may withhold personal information. This can hinder caregivers in their efforts to provide effective interventions or to attain important public health goals. Disclosure of personal health information should protect patient confidentiality as much as possible. Where confidentiality cannot be maintained, clients should be informed regarding how their personal health information will be used and whether the information will be identifiable or anonymous. Coordination of health care in daily practice requires limited disclosure of information to other healthcare providers, or to companies related to client reimbursement or payment, etc. ● Do you work in a massage establishment with more than ten employees? ● Do you file claims with any clearinghouses, such as Availity or Office Ally? ● Do you have general liability insurance or malpractice insurance? ● Do you want to be covered if your session notes are subpoenaed for legal reasons? ● Do you want protection if your client decides to sue you for any reason? (Neeley, 2016) The client records maintained in the practice are the clients and the practitioner is merely the keeper of the information according to HIPAA regulations (Neeley, 2016). The U.S. Department of Health and Human Services has created different kinds of standards for submitting insurance information electronically. These are: 1. Electronic claims submission. 2. Enrollment checking.
PRIVACY AND CONFIDENTIALITY
Massage therapists should keep all original records in their possession. They should provide copies of X-rays, notes, and records documenting client care for clients or healthcare facilities that require copies. Therapists should only share information in cases where disclosure is required by law, court order, or another appropriate, professionally approved manner, according to legal requirements. Practitioners should emphasize the importance of confidentiality and retaining original file copies to all staff members. They should institute the following procedures when providing copies, and make no exceptions: ● Have the client sign and date a release authorization form. ● Keep a copy of the release authorization with the client’s records. ● Copy only the information requested. ● Note in the client’s file: the party requesting the copy; what specifically was requested; the date; and to whom and where the copy was sent. All information and matters relating to a client’s background, condition, and treatment are strictly confidential and should HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects health care consumers’ privacy and stipulates certain rules be adhered to on the part of health care providers (HHS, 2016b). Massage therapists may need to follow HIPAA guidelines. The U.S. Department of Health and Human Services’ definition of a health care provider is “any person or organization that furnishes, bills, or is paid for health care in the normal course of business,” and any health care provider who transmits client records electronically in relation to any health care claim does need to be HIPAA compliant (HHS, 2016b). The following checklist may determine whether the massage therapist or bodywork professional must be compliant with the HIPAA Privacy Rules if they answer, “yes” to the following questions: ● Do you work for someone who files insurance claims, or do you file insurance claims? ● Do you complete an intake form for clients? ● Do you write session notes on clients?
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Book Code: MTX1323
EliteLearning.com/Massage-Therapists
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