More than just an administrative task, clinical records are an essential part of an RMT’s/MT’s practice. Completing records helps capture the clinical reasoning and treatment decisions that informed the care provided and can be relied upon long after the treatment has occurred, supporting patient care, insurance matters, legal proceedings, and regulatory processes.

The following case scenario highlights why timely documentation matters:

Practice Scenario

After several busy days at the clinic, Nathalie, an RMT/MT, notices that completing clinical records between appointments has become increasingly challenging. Looking for ways to improve her documentation practices, Nathalie speaks with a colleague who shares strategies that have helped them maintain timely and complete records. Nathalie begins setting aside dedicated time each day to complete treatment notes and uses an electronic charting system with Subjective, Objective, Assessment, and Plan (SOAP) note templates to help ensure important information is captured accurately.

A few months later, the clinic receives a request for records relating to a patient who was involved in an accident. The records are needed to support ongoing legal proceedings and must be provided within a specific timeframe. Because Nathalie completed the records promptly, the documentation contains details regarding the patient’s health history, assessment findings, treatment provided and the clinical reasoning to support the care delivered, reducing the risk of important details being missed or forgotten and allowing the records to be sent over promptly.

By completing records in a timely manner, Nathalie was able to provide accurate and complete documentation to help support her patient.

For more information about requirements for patient health records, RMTs/MTs can review CMTO’s Guide to Record Keeping Requirements or contact CMTO’s Practice Specialist: practicespecialist@cmto.com.