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 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: ● 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 was the nature of the emergency? ● What signs and symptoms were identified?
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 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 did intervention begin? ● 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. 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.
EliteLearning.com/Massage-Therapists
Book Code: MLA1224
Page 26
Powered by FlippingBook