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. Not all file contents are subject to the same retention times. Massage therapists should 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. They should retain children’s records after they turn 18 for a length of time that equals the state’s statute of limitations. In many states, a therapist is required to keep records for seven years after a client’s last treatment, though in some cases, such as in the state of Washington, the requirement is as little as three years (Thompson, 2018).
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 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 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 (Armstrong, 2012). The recorder should have an accurate time piece to refer to 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 (Armstrong, 2012): ● 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? ● What was the nature of the emergency? ● What signs and symptoms were identified? 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.
● 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?
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. Some guidelines for charting are as follows (Armstrong, 2012): ● 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, and any other significant information.
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Book Code: MFL1225B
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