● When did the emergency occur? ● What was the nature of the emergency? ● What signs and symptoms were identified? ● 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. 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 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. ● 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.
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.
● 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. ● 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).
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Book Code: MTX1225
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