● 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. ● 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. ● 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. 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.
● 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.
PRIVACY AND CONFIDENTIALITY
All information and matters relating to a client’s background, condition, and treatment are strictly confidential and should 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.
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Book Code: MLA1224
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