{"id":3803,"date":"2023-09-28T13:40:19","date_gmt":"2023-09-28T03:40:19","guid":{"rendered":"https:\/\/blog.amt.org.au\/?p=3803"},"modified":"2023-09-28T13:40:23","modified_gmt":"2023-09-28T03:40:23","slug":"keeping-on-top-of-client-records","status":"publish","type":"post","link":"https:\/\/blog.amt.org.au\/index.php\/2023\/09\/28\/keeping-on-top-of-client-records\/","title":{"rendered":"Keeping on top of client records"},"content":{"rendered":"<div class=\"wp-block-image\">\n<figure class=\"alignright size-large is-resized\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" src=\"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?resize=293%2C250&#038;ssl=1\" alt=\"\" class=\"wp-image-3806\" style=\"width:293px;height:250px\" width=\"293\" height=\"250\" srcset=\"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?resize=1024%2C875&amp;ssl=1 1024w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?resize=300%2C256&amp;ssl=1 300w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?resize=768%2C656&amp;ssl=1 768w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?resize=750%2C641&amp;ssl=1 750w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/programmer-3607627_1280.png?w=1280&amp;ssl=1 1280w\" sizes=\"auto, (max-width: 293px) 100vw, 293px\" \/><\/figure>\n<\/div>\n\n\n<p>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 <a rel=\"noreferrer noopener\" href=\"https:\/\/www.amt.org.au\/downloads\/practice-resources\/AMT-code-of-practice-final.pdf\" target=\"_blank\">Code of Conduct<\/a>.<\/p>\n\n\n\n<p>Every version of the National Code states that: \u201cHealth care workers keep appropriate records\u201d.&nbsp; That means that you must keep some kind of record for every client you treat, regardless of the type of massage.&nbsp;<\/p>\n\n\n\n<p><strong>Here are 8 good reasons why you should keep client records.<\/strong>\u00a0<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Client Safety:<\/strong> 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&#8217;s specific needs and avoid potentially harmful situations.&nbsp;<\/li>\n\n\n\n<li><strong>Treatment Planning:<\/strong> Accurate records provide a historical overview of a client&#8217;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.&nbsp;<\/li>\n\n\n\n<li><strong>Legal and Ethical Compliance:<\/strong> Keeping accurate records ensures compliance with both the requirements of the Health Funds as well as compliance to the National Code.&nbsp;&nbsp;&nbsp;<\/li>\n\n\n\n<li><strong>Communication:<\/strong> 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&#8217;s progress and coordinate their care.&nbsp;<\/li>\n\n\n\n<li><strong>Client Relationship:<\/strong> Maintaining accurate records demonstrates professionalism and commitment to the client&#8217;s well-being. It shows that the therapist values the client&#8217;s health and is dedicated to providing the best possible care.&nbsp;<\/li>\n<\/ul>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Consistency<\/strong>: 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&#8217;s needs and progress.&nbsp;<\/li>\n\n\n\n<li><strong>Emergency Situations<\/strong>: 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.&nbsp;<\/li>\n\n\n\n<li><strong>Continuity of Care:<\/strong> If a client returns for massage therapy after a long absence, accurate records can help the therapist recall the client&#8217;s history and any specific concerns, ensuring a seamless continuation of care.&nbsp;<\/li>\n<\/ul>\n\n\n\n<p>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.\u00a0<\/p>\n\n\n\n<p><strong>The top 10 things that every client report should have:<\/strong>\u00a0<\/p>\n\n\n\n<ol class=\"wp-block-list\" start=\"1\">\n<li>Evidence of informed consent.&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"2\">\n<li>Emergency contact details&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"3\">\n<li>Evidence of a comprehensive medical history (tick boxes only does not count)&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"4\">\n<li>Evidence of a medication check&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"5\">\n<li>A short note on the client\u2019s presenting condition and desired outcome of treatment.&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"6\">\n<li>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)&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"7\">\n<li>Details of the treatment protocol (where and how you treated)&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"8\">\n<li>Any observations made during the treatment&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"9\">\n<li>Results and retesting.&nbsp;<\/li>\n<\/ol>\n\n\n\n<ol class=\"wp-block-list\" start=\"10\">\n<li>Your signature, date and duration of the session.&nbsp;<\/li>\n<\/ol>\n\n\n\n<p>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.\u00a0 Fenton Green, AMT\u2019s preferred provider advise if there are no treatment notes then any claim against you is very difficult to defend.<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"alignleft size-large is-resized\"><img data-recalc-dims=\"1\" loading=\"lazy\" decoding=\"async\" src=\"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?resize=403%2C268&#038;ssl=1\" alt=\"person writing\" class=\"wp-image-486\" style=\"width:403px;height:268px\" width=\"403\" height=\"268\" srcset=\"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?resize=1024%2C683&amp;ssl=1 1024w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?resize=300%2C200&amp;ssl=1 300w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?resize=768%2C512&amp;ssl=1 768w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?resize=750%2C500&amp;ssl=1 750w, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?w=1920&amp;ssl=1 1920w\" sizes=\"auto, (max-width: 403px) 100vw, 403px\" \/><\/figure>\n<\/div>\n\n\n<p>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.&nbsp;&nbsp;<\/p>\n\n\n\n<p>If you would like to refresh the standards for report writing, AMT have a recorded webinar \u201crecord keeping \u2013 back to basics\u201d for purchase for $20 <a href=\"https:\/\/form.jotform.com\/220740209225850\" target=\"_blank\" rel=\"noreferrer noopener\">here<\/a>.&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Client records are not just something required for health funds.  Every treatment, regardless of the type or duration must be appropriately documented.<br \/>\nFind out more about what is required in this blog.<\/p>\n","protected":false},"author":1,"featured_media":3805,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"jetpack_post_was_ever_published":false,"_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[32,110,164,252,50,2,911],"tags":[522,909,47,10,853,521],"class_list":["post-3803","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-amt","category-clinical-practice","category-continuing-education","category-health-funds","category-members","category-professional-practice","category-record-keeping","tag-amt-code-of-practice","tag-compliance","tag-massage-therapist","tag-massage-therapy","tag-record-keeping","tag-standards"],"jetpack_featured_media_url":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2023\/09\/cabinet-1293245_1280.png?fit=1280%2C1040&ssl=1","jetpack_likes_enabled":true,"jetpack_sharing_enabled":true,"jetpack-related-posts":[{"id":3574,"url":"https:\/\/blog.amt.org.au\/index.php\/2022\/03\/30\/amt-chairperson-autumn-2022-message\/","url_meta":{"origin":3803,"position":0},"title":"AMT Chairperson Autumn 2022 Message","author":"admin","date":"30\/03\/2022","format":false,"excerpt":"How well written are your treatment notes? Would they stand up to scrutiny in a courtroom? AMT Chairperson Subhadra Gerard is here to spell out the importance of record keeping.","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2022\/03\/vinyl-1595847_640.jpg?fit=640%2C480&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2022\/03\/vinyl-1595847_640.jpg?fit=640%2C480&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2022\/03\/vinyl-1595847_640.jpg?fit=640%2C480&ssl=1&resize=525%2C300 1.5x"},"classes":[]},{"id":484,"url":"https:\/\/blog.amt.org.au\/index.php\/2018\/01\/17\/being-a-health-fund-provider-your-responsibilities-and-obligations\/","url_meta":{"origin":3803,"position":1},"title":"Being A Health Fund Provider: Your Responsibilities And Obligations","author":"admin","date":"17\/01\/2018","format":false,"excerpt":"What are your responsibilities and obligations as a massage therapy provider? What records do you need to maintain and keep? And how do you avoid committing health fund fraud? Some simple guidelines and reminders to follow as a provider to private health funds.","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"person writing","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?fit=1200%2C800&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?fit=1200%2C800&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?fit=1200%2C800&ssl=1&resize=525%2C300 1.5x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?fit=1200%2C800&ssl=1&resize=700%2C400 2x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/01\/writing-828911_1920.jpg?fit=1200%2C800&ssl=1&resize=1050%2C600 3x"},"classes":[]},{"id":1512,"url":"https:\/\/blog.amt.org.au\/index.php\/2019\/03\/21\/modality-jiggery-pokery\/","url_meta":{"origin":3803,"position":2},"title":"Modality Jiggery Pokery*","author":"admin","date":"21\/03\/2019","format":false,"excerpt":"AMT recently had some dialogue with Federal Health Minister, Greg Hunt regarding the April 1 changes to private health insurance rules. Rebecca Barnett reports that we might be scratching our heads even more now.","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/03\/private-health-insurance-1200x72-1.jpg?fit=750%2C442&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/03\/private-health-insurance-1200x72-1.jpg?fit=750%2C442&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/03\/private-health-insurance-1200x72-1.jpg?fit=750%2C442&ssl=1&resize=525%2C300 1.5x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/03\/private-health-insurance-1200x72-1.jpg?fit=750%2C442&ssl=1&resize=700%2C400 2x"},"classes":[]},{"id":749,"url":"https:\/\/blog.amt.org.au\/index.php\/2018\/05\/04\/amt-position-statement-on-the-provision-of-mobile-massage-therapy-services\/","url_meta":{"origin":3803,"position":3},"title":"AMT Position Statement on the Provision of Mobile Massage Therapy Services","author":"admin","date":"04\/05\/2018","format":false,"excerpt":"AMT has released a position statement on the provision of mobile massage therapy services that describes the benefits and evidence to support in-home and corporate massage services.","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/05\/amt-position-statement-1.png?fit=560%2C315&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/05\/amt-position-statement-1.png?fit=560%2C315&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2018\/05\/amt-position-statement-1.png?fit=560%2C315&ssl=1&resize=525%2C300 1.5x"},"classes":[]},{"id":2174,"url":"https:\/\/blog.amt.org.au\/index.php\/2019\/11\/21\/out-with-the-old\/","url_meta":{"origin":3803,"position":4},"title":"Out with the old &#8230;","author":"admin","date":"21\/11\/2019","format":false,"excerpt":"AMT has recently completed its annual review of the AMT Code of Practice. And this time around, we've made one really exciting change, beyond reviewing the currency of legislation that applies to the practice of massage therapy ...","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/11\/Change.jpg?fit=960%2C611&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/11\/Change.jpg?fit=960%2C611&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/11\/Change.jpg?fit=960%2C611&ssl=1&resize=525%2C300 1.5x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2019\/11\/Change.jpg?fit=960%2C611&ssl=1&resize=700%2C400 2x"},"classes":[]},{"id":3879,"url":"https:\/\/blog.amt.org.au\/index.php\/2024\/05\/20\/10-reasons-to-be-excited-about-amts-new-research-resource\/","url_meta":{"origin":3803,"position":5},"title":"10 reasons to be excited about AMT&#8217;s new research resource","author":"admin","date":"20\/05\/2024","format":false,"excerpt":"Drum roll please ... Unveiling the new AMT research resource: your backstage pass to the cutting-edge of massage therapy, where evidence meets innovation in one shiny, digital package.","rel":"","context":"In &quot;AMT&quot;","block_context":{"text":"AMT","link":"https:\/\/blog.amt.org.au\/index.php\/category\/amt\/"},"img":{"alt_text":"","src":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2024\/05\/Library.png?fit=1200%2C673&ssl=1&resize=350%2C200","width":350,"height":200,"srcset":"https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2024\/05\/Library.png?fit=1200%2C673&ssl=1&resize=350%2C200 1x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2024\/05\/Library.png?fit=1200%2C673&ssl=1&resize=525%2C300 1.5x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2024\/05\/Library.png?fit=1200%2C673&ssl=1&resize=700%2C400 2x, https:\/\/i0.wp.com\/blog.amt.org.au\/wp-content\/uploads\/2024\/05\/Library.png?fit=1200%2C673&ssl=1&resize=1050%2C600 3x"},"classes":[]}],"_links":{"self":[{"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/posts\/3803","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/comments?post=3803"}],"version-history":[{"count":2,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/posts\/3803\/revisions"}],"predecessor-version":[{"id":3807,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/posts\/3803\/revisions\/3807"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/media\/3805"}],"wp:attachment":[{"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/media?parent=3803"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/categories?post=3803"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blog.amt.org.au\/index.php\/wp-json\/wp\/v2\/tags?post=3803"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}