● Following generally accepted accounting practices. ● Keeping accurate financial records. ● Maintaining patient confidentiality. ● Respectful and cooperative collaboration with other professionals. ● Appropriate referrals, if necessary. As a massage professional, any negative perceptions of your marketing materials or advertisements tend to reflect Documentation and records Proper documentation and record keeping is a critical, routine aspect of a successful practice. Keep notes legible and accurate. If it is ever necessary to refer to files at some time in the future (a medical emergency or legal proceedings, for example), the context and details of your notes should be clear. Other health care personnel will need to know the background, presenting status, actions taken and the results, with some discussion of treatment strategies and expected objectives. Adhere to the following guidelines for preparing and maintaining records: 9 ● Maintain accurate and truthful records. Record only factual information, observations, and actions. Don’t record your opinions, or conjecture about the client or his/her condition. When recording statements made by your client (regarding an injury, for example), use quotation marks to demarcate the client’s words. Keep a separate file for personal notes or any material of a speculative nature. ● Make sure the forms you use to collect client information are appropriate to your practice and cover all pertinent areas. Make sure forms are free of errors and are easy to read and understand. Questions should be stated simply. Avoid jargon or complicated medical terminology, or define terms, as needed. 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, his or her reason(s) for seeking massage therapy, onset and duration of problematic symptoms, medical history of family members (if appropriate), and occupational background. ● Train staff members 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. Implement some structure or mechanism to ensure this information is complete for every client and answers are recorded in sufficient detail. 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” (non applicable) rather than left blank. Confidentiality Keep all original records in your possession. Provide copies of x-rays, notes, and records documenting client care for clients or health care facilities requiring their own copies. Share information only in cases where disclosure is required by law, court order, or another appropriate, professionally approved manner, according to legal requirements. Impress the importance of confidentiality and retaining original file copies upon all staff members. Institute the following procedures when providing copies, and make no exceptions:
poorly on your colleagues and the profession as a whole. Promotional materials should: ● Include your license number, place of business, and phone number. ● Refrain from using fear or guilt as motivational tactics. ● Avoid unrealistic, misleading, or sensational claims, or promises to cure specific conditions or ailments. ● Avoid using any wording or image that might be construed as sexual in nature. ● Adhere to truth-in-advertising standards. ● Develop a short, simple form that clients can use to note their progress (or lack of progress) at each visit. ● Document any client non-compliance with the care plan, including canceled appointments (DNKA = did not keep appointment), refusal or failure to follow health care instructions and/or take needed medication, activities or behaviors that pose a risk to the client’s health. Communicate the rationale for your opinion and do not proceed with any action that conflicts with your professional judgment. ● If you feel the client’s disregard for professional recommendations is putting him or her at risk, have the client sign a form acknowledging that he or she has been informed of the potential consequences of their action or inaction, and is choosing to refuse recommended treatment. ● Notes should be legible as well as accurate. Pay attention to your handwriting and use clearly written and recognized abbreviations. Remember that you and other people may need to refer to these notes years in the future. Make sure they are 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 health care environments: ○ Alter records as minimally as possible, and only when necessary. ○ If you find something in error, do not erase. Cross out the error using a single line, so as not to conceal what is written underneath, and write the word “error” above the incorrect statement. ○ If you review your records and feel the need to clarify a point, write the date and the additional comments with the note (labeled “addendum”). ○ If litigation is threatened, do not make any kind of change to the records. Not all file contents are subject to the same retention times. 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. Retain children’s records after they turn 18 for a length of time that equals the state’s statute of limitations. ● 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, and the date, to whom, and where the copy was sent.
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Book Code: MIL1224
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