improve digestion, promote healthy sleep, and improve memory or concentration (AMTA, 2021c). Today, massage and bodywork practitioners may serve as part of a multidisciplinary health care team, and have the responsibility to collaborate with other health care providers to help clients achieve wellness goals. Clients regard their health professionals as role models for health and wellness, which adds to the importance of practitioners to maintain a healthy lifestyle and balance in their lives. To be regarded as health care professionals, practitioners must exemplify ethical standards in their daily practice and in the community. Self-care to maintain a successful practice The AMTA provides the following information of the importance of self-care to support a successful practice (AMTA, 2021c): Practicing self-care is as important to your business success as your client and business skills are. If you injure yourself through poor use of body mechanics or physical exhaustion, the effect on your business could 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
be devastating. A healthy self-care routine allows you to take on the demanding yet satisfying work required of massage therapists. Take care of yourself and your business at the same time. The AMTA provides the following tips for self-care on and off the job (AMTA, 2021c): • On-the-job self-care tips include: ○ Consistently good body mechanics ○ Breathwork ○ Meditating or praying ○ Quiet breaks ○ Healthy eating • 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 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.
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