Maintenance of Client Records

Background

Massage therapists have a duty to the client to make and maintain proper records of any professional interaction. There are four primary reasons for keeping a client health record:

  1. It assists the Massage Therapist in recalling details of the client’s history, condition, and the treatment provided;
  2. It assists the continuity of care if colleagues or a locum are called upon to treat the client;
  3. It provides a record for medical legal purposes when the client requires a report relating to the illness or injury treated; and
  4. It provides a record of events for the Massage Therapist in the event subsequent inquiries relating to the treatment are made by insurers or a complaint against the Massage Therapist is submitted to the College.

Policy

Massage therapists are required to:

  1. Make and maintain client records relating to the provision of Massage Therapy services.
  2. Maintain client records for up to ten years from the date of the last entry, or if the client is less than 18 years old, 10 years from the date the client becomes 18 years of age. Massage therapists may retain personal possession of the records or make arrangements for a custodian to assume this responsibility.
  3. Ensure that the confidentiality of client information is maintained.
  4. Release information contained in the client’s health record with the client’s consent.

Principles

The following principles should be adhered to in dealing with the maintenance, access to and/or release of client files.

  1. All information relating to the Massage Therapy services provided to a client is to be treated as confidential.
  2. The health information contained in the file belongs to the client and can be released only with his/her consent or as required by law.
  3. The client has a right to access the information contained in his/her health record.

Approved: June 19,1995
 Revised: November 19, 1999
References: The Massage Therapy Act, Ontario Regulation 544/94, Part III, Records