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Keeping on top of client records

There is a common misconception in some parts of the industry that client records are only required if you are providing remedial massage that is claimable for a health fund rebate. Whilst detailed records that meet the Health Fund reporting requirements are important, as health service providers, massage therapists have a legal obligation to comply with the requirements of the Federal Privacy Act and relevant state health records legislation in the collection and management of personal information, including health information, as well as the record keeping requirements of the National Code of Conduct relevant to your state. Also, as a member of AMT, you are required to adhere to our record keeping standards outlined in the Code of Conduct.

Every version of the National Code states that: “Health care workers keep appropriate records”.  That means that you must keep some kind of record for every client you treat, regardless of the type of massage. 

Here are 8 good reasons why you should keep client records. 

  • Client Safety: Keeping accurate records helps ensure the safety of the client. By documenting any pre-existing medical conditions, allergies, medications, or injuries, the therapist can tailor the massage session to the client’s specific needs and avoid potentially harmful situations. 
  • Treatment Planning: Accurate records provide a historical overview of a client’s health and treatment progress. This information helps the therapist plan future sessions effectively, adjust techniques, and measure the effectiveness of the treatments over time. 
  • Legal and Ethical Compliance: Keeping accurate records ensures compliance with both the requirements of the Health Funds as well as compliance to the National Code.   
  • Communication: Accurate records facilitate communication among healthcare providers. If a client is receiving massage therapy as part of a broader healthcare regimen, having detailed records can help other healthcare professionals understand the client’s progress and coordinate their care. 
  • Client Relationship: Maintaining accurate records demonstrates professionalism and commitment to the client’s well-being. It shows that the therapist values the client’s health and is dedicated to providing the best possible care. 
  • Consistency: Accurate records help ensure consistency in the treatment provided. If multiple therapists are working with the same client, having comprehensive records ensures that each therapist is on the same page regarding the client’s needs and progress. 
  • Emergency Situations: In the rare event of a medical emergency during a massage session, having client records readily available can provide essential information to first responders or medical personnel. 
  • Continuity of Care: If a client returns for massage therapy after a long absence, accurate records can help the therapist recall the client’s history and any specific concerns, ensuring a seamless continuation of care. 

All health records must be able to be reproduced if required. They must be sufficiently clear, structured and detailed to enable another person to understand them, they must be sequential, kept for a minimum of 7 years, must be a true reflection of the treatment and it must be in English. 

The top 10 things that every client report should have: 

  1. Evidence of informed consent. 
  1. Emergency contact details 
  1. Evidence of a comprehensive medical history (tick boxes only does not count) 
  1. Evidence of a medication check 
  1. A short note on the client’s presenting condition and desired outcome of treatment. 
  1. Brief summary of clients presenting conditions including any pathology/xrays etc and your own assessment (note for HF compliance you must conduct a minimum of two tests at start and again at the end of the treatment) 
  1. Details of the treatment protocol (where and how you treated) 
  1. Any observations made during the treatment 
  1. Results and retesting. 
  1. Your signature, date and duration of the session. 

AMT staff are often called to give expert witness testimony in legal proceedings. Treatment notes are your evidence against claims and litigation. Meticulous and comprehensive records of the treatment ensure that if a claim is made against us, we can back up and support the treatment provided and rationale behind it.  Fenton Green, AMT’s preferred provider advise if there are no treatment notes then any claim against you is very difficult to defend.

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Maintaining accurate client records is not only a legal and ethical obligation for massage therapists but also a fundamental aspect of providing safe, effective, and client-centred care. It supports client safety, treatment planning, communication, and the overall professionalism of the therapist.  

If you would like to refresh the standards for report writing, AMT have a recorded webinar “record keeping – back to basics” for purchase for $20 here

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  1. Phillip Boelen
    09/12/2023 - 10:33 am

    Hi , I am looking for a client intake form that is not internet based. There a few I look at like Fresha and Cliniko that seem to be internet based .

    Is there a program or computer based intake for I can get?

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