AMT Chairperson Autumn 2022 Message
By Subhadra Gerard
Record Keeping Is Not Just About Your Vinyl Collection
Earlier this month I attended the AMT webinar presented by Fenton Green, AMT’s preferred insurer. Very informative and thought-provoking, it was. The speaker, Monique Sollis, covered various aspects of professional indemnity and public liability insurance, but I was particularly interested in the conversation about the role comprehensive notes can play in the event of a claim.
Monique identified several mitigation strategies that we therapists should action to reduce or eliminate the risk of a claim against us. Right at the top of the list was having appropriately comprehensive clinical documentation and file keeping in place. Monique went on to say that the biggest claims issue is therapists NOT having any documentation at all, or only vague documentation. I found that quite extraordinary. Claims then degenerate into a “he said, she said” matter. And this makes it hard for the insurer to defend the claim, even if the therapist has done nothing wrong. As I can only reiterate: “the better your contemporaneous documentation, the better your defence”.
Monique shared an example wherein a client presented at a massage therapist’s clinic for a remedial massage. During the massage it transpired that one of the client’s ribs was fractured, with immediate resultant pain. The main record keeping issues raised were:
- The client hadn’t adequately completed a ‘New Client’ form. There were no details about pre-existing injuries.
- The therapist didn’t have accurate clinical notes outlining the treatment provided.
- It was discovered within the litigation process that the client had broken their ribs (in question) in the past.
Watch the webinar here.
Here are three examples of my own to add to the mix. (From time to time I am asked by law firms, acting on behalf of insurance companies, to provide an expert opinion on the standard of care provided by massage therapists.)
- A client presented at a multi-practitioner massage therapy clinic complaining of unspecified back pain and elected to receive an aromatherapy massage. No adverse report was made at the end of the massage, but on a later day a claim was made by the client that the massage caused a lower back injury, namely a prolapsed disc.
- A client presented at a multi-practitioner massage therapy clinic complaining of an increase in lower back pain ex an historical occupational injury. The client had undergone surgery some years prior. The client received a small number of short massage treatments, from different staff. Following the last treatment session, the client was in increased pain, which became severe in the following hours, requiring medical treatment. At a later date a claim was made by the client that the last massage treatment caused a nerve compression injury.
- A regular client presented at a massage therapy clinic for their usual full-body remedial massage (with the same therapist). A number of sore/tight areas were circled on the client form. Nothing untoward happened during the massage, but in the following days, the client experienced neck stiffness/soreness, and later again, neurological symptoms. At a later date a claim was made by the client that the latest massage treatment caused a neck lesion leading to neurological incapacitation.
There were quite different narratives going on with these three legal cases, but in terms of our current conversation the record keeping issues were strikingly similar. In all examples, there was:
- No evidence of a relevant client health history being undertaken
- Insufficient evidence as to the nature of the presenting condition
- Only a scant record of any investigation of the nature of the client’s pain
- Insufficient evidence of any relevant physical assessments
- No evidence of a treatment plan
- Only a scant record of treatment techniques. In one example of case notes, the first treatment was recorded in one word, “massage”, with the follow-up session treatment recorded as “same as last time”
- Insufficient evidence of post treatment evaluation of the client.
So, in effect, these examples are very much in accord with Monique’s comments above regarding the main issue with insurance claims.
There are some pretty obvious reasons for keeping appropriate clinical records, including to:
- enable the therapist to track a client’s progress
- assist the therapist to recall previous assessment, treatment and evaluation, enabling the therapist to deliver more specific and beneficial treatment
- allow the therapist to communicate with other health care professionals in the same clinic, or other clinics, who may be treating the same client
- form a part of any medico-legal report that the therapist may be required to produce; e.g. Workers Compensation, motor vehicle injury
- provide the therapist with accurate information of the entire consultation if the therapist is called as a witness in any legal proceeding1
To complete the picture, there are a couple of added benefits to keeping comprehensive clinical notes:
- They can be used for quality assurance and improvement purposes; e.g. as an excellent case study resource for when the therapist next has to present at the monthly PD session the clinic runs.
- They can be used in outcomes research; e.g. in determining the effectiveness of a specific formula of myofascial techniques as a therapeutic intervention in the treatment of TMJ-related pain.
And finally, there are third-party players that therapists have obligations to, namely:
- their professional association
- (for most therapists) various private health funds
- federal and/or state/territory statutory bodies (I’m referring here to the need to comply with the (Federal) The Privacy Act 1988, and health record legislation in the ACT, NSW and Victoria – if you practice in those jurisdictions)
So firstly, what about the health funds? In preparation for writing this article, I had a look at the top five health insurance funds in Australia, by market share (MBP/AHM, BUPA, HCF, NIB, HBF)2, and checked out their clinical record keeping standards for Recognised Providers. There were no surprises there, with all the funds, in a nutshell, stipulating that Providers must maintain full patient records for each treatment. All the funds, just to make things clear, reinforced that position by stipulating that Providers must comply with the standards of their professional association.
That leaves the obligations to the professional association. Ok, so we all know that AMT members are required to comply with the AMT Code of Practice, which basically means adhering to all the Standards in said Code of Practice.
“Record keeping is an important component of competent professional practice and essential to the delivery of quality evidence-based health care. Massage therapists must create and maintain health records that serve the best interests of clients, and that contribute to the safety and continuity of their health care”3.
AMT Code of Practice
It’s important to bear in mind here that the AMT Record Keeping Standard didn’t arise out of thin air, but instead clearly reflects all the documentation training embedded throughout the Diploma of Remedial Massage. I put it to you that a good proportion of we massage therapists, having received a quite adequate, if not bloody wonderful, standard of training in the Diploma of Remedial Massage, now maintain professional, comprehensive record keeping in our clinical practice. And a big thank you to you all for doing so.
My suspicion, though, is that there are a fair few massage therapists in clinical practice who, for one reason or another, haven’t had an adequate level of training in record keeping and are currently all-at-sea when it comes to maintaining appropriate clinical records. I have been approached personally by a couple of massage therapists in my local area, lamenting their poor skills, and asking for 1:1 tutorials on clinical notetaking (to which I’ve happily obliged), but I am sure there is a broader need out there.
Sometimes it can be a matter of simply reviewing the basics. For example, it is common for professional therapists to adopt a strategy or a ‘formula’ for completing each client consultation in a thorough and precise manner. Depending on where you did your training in massage, you will have heard of charting system examples, like ASTER and SOAPIER (my favourite):
A – Assess client needs
S – Select treatment plan
T – Treat
E – Evaluate
R – Record
S – Subjective information (what the client states or feels)
O – Objective information (what the therapist can measure or factually describe)
A – Assessment (what the therapist determines to be the cause of the problem or need)
P – Plan (general statement of the plan of action to be taken)
I – Intervention (the specific action taken)
E – Evaluation (an appraisal of the response and effectiveness of the plan)
R – Revision (a review of what to do next; possible adjustments to ongoing care plan; any ‘homework’)
So, where to from here?
The wonderful Liz Sharkey from Massage Training Australia is presenting the April AMT webinar, ‘Record keeping – Back to Basics’ on Monday, 11 April 2022 at 12pm AEDT (check your world clock for viewing time in your location). Liz will be reviewing record keeping compliance standards in relation to the AMT Code of Practice, private health fund requirements, as well as statutory requirements in our various jurisdictions. Just what the doctor ordered!
Register for Liz’s webinar here.
If you want to find out what the six other top mitigation strategies are that Monique Sollis suggested we therapists should action to reduce or eliminate the risk of a claim against us, then watch the Fenton Green webinar (above).
- Casanelia, L. & Stelfox, D. (2010). Foundations of Massage (3rd ed.). Churchill Livingstone, p.109.
- Massage Therapy Code of Practice, Association of Massage Therapists Ltd, p.36.
About The Author
Subhadra Gerard is a massage therapist and occupational therapist in Perth, WA. He took on the role of Chairperson of the AMT Board of Directors in May 2021.