Set the record straight
The general practice policies for record-keeping deal with the procedures you have set up in the front office: your fee schedule, cancellation policy, appointment record and privacy plan.
By Andrea Collins
The fee schedule needs to be posted where all the patients can see it and explain that the rates include the treatment time as well as intake and assessment. If you deviate from this set schedule, the patient must agree and the reason must be documented in the clinical notes.
The cancellation policy must also be clear and explained to the patient. You could have a sign on your front desk so the patients can see it, but you could also include it on the intake form where the patient signs. The cancellation policy can be a challenge to enforce, especially when just starting a practice and during a growth stage. It is very hard to ask patients to pay for a cancelled appointment when you want them to come back for more appointments. As you become busier, the cancellation policy is easier to enforce as you are losing money with a “no show” or a late cancellation. Having a policy in place for patients who are chronically late or cancel at the last minute will help give you structure to deal with this.
The daily appointment record is important and valuable for many reasons. It is a regulatory requirement that you keep the patients’ name and timing/duration of each appointment. If you work in a large clinic where all therapists work from the same book or program (if digital), you will need a copy for your own records. Not all business relationships last and you may not have access if you leave. The appointment record not only satisfies a legislative requirement but will also help you determine your hours each year for your registration renewal.
Renewal with the College of Massage Therapists of Ontario (CMTO) requires you to provide the number of weeks you worked, and average number of hours per week. For Ontario and Newfoundland & Labrador, you also need to confirm that you have done 500 hours of treatment every three years – rolling. This calendar can also act as the tracking record for equipment checks, equipment service and cleaning records that need to be maintained (quality assurance program and regulatory requirement for Ontario). This does not need to be a big, fancy agenda; a simple weekly or daily calendar that can fit all your appointments is sufficient.
There are two privacy legislations that we need to be aware of: Personal Information Protection and Electronic Documents Act (PIPEDA) for federal; and respective provincial legislations (PHIPA for Ontario, E-Health Act for BC, PHIA for Newfoundland, PHIPAA for New Brunswick, to name a few). These laws cover how we should deal with health information. The province you are in, and the legislation in that province, will change how you need to deal with maintaining the confidentiality of your patients’ personal and health information. Some of the key points massage therapists need to be aware of are as follows.
Within the above forms you will need to let your patients know why you are collecting the information, what will be done with it, and that you will be keeping it confidential unless required to share it by law. Various locations and clinical situations will have drastically different reasons for collecting information, such as research data, quality improvement and risk management activities. At most small massage clinics, the reasons will be much more streamlined.
You need to identify someone in your practice as the primary contact for the management of your privacy plan and this should be indicated to your patients.
Your health history form may also be used to help develop your business by asking for permission to send out newsletters or asking how the person found you, giving you valuable information about your advertising strategies. For more information about intake forms, you can review Massage Therapy Canada Magazine article, “The health history form: Making the most of the patient intake process” (www.massagetherapycanada.com/content/view/2105/). The health history form must be updated yearly. If the patient has not seen you in a number of years you could have them fill out a new form.
Record of consent of assessment and/or treatment must also be recorded for every treatment. Many clinics have a statement on their intake form that includes the patient giving consent to the treatment. Unfortunately, this practice is incorrect. A patient may not give consent to a treatment that you have not even proposed yet. The intake form may contain a statement that states something similar to, “I am aware that I will be asked for consent for treatment at the beginning of each treatment after my therapist has proposed a treatment plan and that I may withdraw my consent at any point during the treatment by verbalizing this to my therapist.”
This informs the patient that they have the power not only to consent, but also to withdraw their consent at any time. This consent needs to be recorded in the treatment notes within 24 hours of treatment.
Every treatment that you perform, regardless of length or fee, you must record certain information for charting. This information will vary slightly
depending on the province but relates to:
- exam(s) and results
- reports from other health-care providers
- date, time and duration of treatment
- fee for treatment
- results from assessment techniques used by the therapist
- summary of techniques used and areas treated
- patient reaction/feedback to treatment
- informed consent from the patient/substitute decision-maker
- used and/or recommended remedial exercises
- hydrotherapy applications and/or self care, and
- updated health history and treatment information as obtained
The format of how this information maintained is up to each clinic/therapist. You can choose between regulatory college templates, you can create your own paper versions, or choose to go digital with a program, either online or offline. Whichever option you choose, all the pertinent information must be recorded within 24 hours of the treatment (as per Ontario and Newfoundland regulations). If you decide to choose digital files you need to ensure that you are complying with Canadian privacy legislation.
If you choose the services of a company outside Canada, they have to abide by privacy legislation where they are located – which could be drastically different than the Canadian federal or provincial laws, and you could be putting yourself at risk.
All of our records must be kept in a secure location so all the information are kept confidential. This could mean a filing cabinet that is locked when left unattended (while in treatment). You could also store the files in a locked staff room. Any information that is stored on a mobile device must be secured with strong encryption – and password protection is not enough (for further specifics, check your privacy legislation).
For file retention, there are two guidelines that the regulated provinces fall under. For Ontario, Newfoundland & Labrador, and New Brunswick, you must keep your files for 10 years following the last appointment. If the patient was under 18 years of age you must keep the files for 10 years following their 18th birthday. Therapists in British Columbia must maintain original files for 16 years. If the patient is under 19 years of age you must keep the files for 16 years following the patient’s 19th birthday. B.C. has additional stipulations surrounding files and how they are maintained. See College of Massage Therapists of B.C. Bylaws for more information.
After the prescribed time you must destroy the files, according to what is described in your province’s privacy laws. Under Ontario rules, the files must be disposed of in a secure manner, such that the records cannot be reconstituted – for example, a cross cut shredder versus a regular shredder.
You need to make sure that you have set guidelines regarding the management of files when you start your working relationship with a clinic. Set a good contract to protect yourself in case you are working in a location and choose to leave. If you are working in a clinic with other regulated health-care professionals, you should get a statement that they will maintain the files according to the legislation (and identify the specifics) and both parties have to sign. You might also want to have copies or, at a minimum, be able to have access to the files if for some reason you need access to them in the future (e.g. patient requiring information for legal reasons).
If you are working in a location that does not have another regulated therapist, you are prohibited from leaving your files at the location. This may occur in a small spa where the owner is a businessperson or esthetician. Your files are covered under the regulated health professions legislation and you are not permitted to leave your files with someone who is not required to maintain the record to our regulations.
Having knowledge about proper record management is essential for any massage therapist who wants to stay in good standing with their regulatory college and with the government. If you choose to strive for best practice, your attention to a higher standard will help elevate the opinion of massage therapy to the public, other health-care professionals and to the government. By raising the standards that massage therapists strive for, our profession may continue to gain acceptance as a part of mainstream health care.
(Note: This article primarily covers the Ontario regulations. The other regulated provinces may have similar policies and procedures. To ensure that you are compliant with the correct regulations please consult your respective provincial legislation.)
Andrea Collins is an author, educator, speaker and registered massage therapist. Contact her at firstname.lastname@example.org.