Record Keeping

Guide to Record Keeping Requirements

Registered Massage Therapists (RMTs/MTs) are expected to prepare accurate and complete client health records and other documentation. A client health record is any document related to the assessment or treatment of a client. Records must be maintained, stored, transferred and disposed of in a way that keeps client information confidential and secure.

To do this, RMTs must take certain steps and regularly verify that all records are kept in compliance with the Personal Health Information Protection Act, 2004 (PHIPA), the Records Regulation (Part III of the General Regulation of the Massage Therapy Act, 1991), and the Records and Record Keeping sections of the Professional Misconduct Regulation in the Massage Therapy Act, 1991. These requirements are summarized below.

All requirements apply whether the records are in paper or electronic form. RMTs may follow an employer’s record keeping protocols as long as they meet the minimum requirements below.

Record Keeping: General

RMTs must protect the confidentiality of all reports and records, including protection from loss, tampering, interference, or unauthorized use or access. RMTs must retain records for required time periods (please see “Requirements for Client Health Records” below).

RMTs who are Health Information Custodians (HICs) must:

• take reasonable steps to ensure that client personal health information is as accurate, complete and up-to-date as necessary for providing treatment;
• ensure that client personal health information is protected against theft, loss and unauthorized use or disclosure and protected against unauthorized copying, modification or disposal;
• notify the client at the first reasonable opportunity if their personal health information is stolen, lost, used or disclosed without consent; and
• if using electronic methods to collect, use, share, modify, retain or dispose of personal health information, RMTs must ensure an electronic audit log is maintained.

Do’s and Don’ts of Record Keeping

The Professional Misconduct Regulation under the Massage Therapy Act, 1991 outlines the following Do’s and Don’ts of Record Keeping.

Do:

• provide copies of a client health record when requested by a client, a client’s authorized representative, and/or required or allowed by law;
• transfer client records when the RMT retires, moves practices or locations, or when otherwise requested by the client; and
• provide a report or certificate related to a service or treatment when a client or their authorized representative makes a request.

Don’t:

• allow an individual to examine a client record or provide information from it, when it’s not allowed or required by law;
• falsify records; and
• sign or issue a document that the RMT knows includes a false or misleading statement.

Records That Must be Kept

RMTs must maintain the following records:

1. A daily record with the name and appointment/treatment time of each client;
2. An equipment service record documenting the servicing of equipment used to treat clients;
3. Financial records for each client; and
4. Personal health record for each client.

Requirements for Financial Records and Receipts

A financial record, which is required for each client, must contain:

1. the treatment and service provided;
2. fees charged; and
3. a copy or record of receipts, which must include:
   1. date of appointment;
   2. name of the client;
   3. name of RMT;
   4. cost/fee for the treatment or service;
   5. signature and registration number of the RMT; and
   6. HST number (if applicable).

RMTs cannot issue receipts for Massage Therapy or use their College registration number for services, treatments, techniques and modalities that are:

• outside the Scope of Practice for Massage Therapy;
• not provided in compliance with the Standards of Practice; or
• not part of a Massage Therapy treatment plan.

Please review the Standard of Practice: Fees & Billing to learn more about billing Massage Therapy treatments, including requirements for receipts and gift certificates.

Requirements for Client Health Records

A health record is required for each client. Each part of the record must be dated and identify the client. The record must contain:

1. the client’s name and address.
2. the date, time and duration of each of the client’s visits to the RMT.
3. the name and address of the primary care physician and any referring health professional.
4. any relevant medical history and a history of Massage Therapy.
5. information on every examination performed by the RMT and every clinical finding and assessment made by the RMT.
6. every written report received by the RMT with respect to examinations, tests, consultations or treatments performed by any other person.
7. details of all advice given by the RMT.
8. information on every referral of the client by the RMT to another health professional.
9. details of every fee or other amount charged by the RMT.
10. a copy of every written consent.
11. a copy of every needs assessment.
12. a copy of any treatment plan.
13. details of the treatment applied at each of the client’s visits by the RMT and the name of the RMT who applied the treatment.

Client health records must be retained for 10 years after the client’s last visit, or 10 years after the day the client turned 18 (if they were under 18 at the time of their visit). Destroying records must only be done after this time period, and in a way that maintains client confidentiality.

Sharing Records

When RMTs receive a written request, they must share copies of a client health record with:

• the client.
• a personal representative of the client who the client authorized in writing to obtain copies of the record.
• if the client is dead, a legal representative of the client.
• if the client is incapable, their substitute decision-maker.

It may be considered professional misconduct to deny this request. RMTs may charge a reasonable fee for this service.

If RMTs receive a request from an insurer or other third party to share a copy of a health record, they must obtain written consent from the client before releasing the record.

For the purpose of providing care, RMTs may allow other health professionals to review the client health record and RMTs may share information from the client record with other health professionals.

HICs have a client’s implied consent to share personal health information within the circle of care if it is for the purpose of providing or assisting with care.

Records Retention: Employment/Practice Location Changes and Death

When entering a new practice, an RMT should have a written agreement with their employer or the facility operator. Agreements must state the procedures for record storage, which would address any circumstance where the RMT ceases to work at that practice, including in cases of termination of employment and the practice closing, relocating or being sold. RMTs must ensure that any agreement they enter into allows them to comply with their legislated record keeping requirements (i.e., those in the Massage Therapy Act, 1991 noted above, PHIPA, etc.)

If the RMT’s employment relationship with a practice ends and the RMT is not the HIC, there should be a plan for the RMT to be given copies or access to client records.

If the RMT is to maintain storage of the records, the facility will need information on how to contact the RMT (for example, contact information for their new practice location) to be able to provide clients access to their records.

Since it is an act of professional misconduct to abandon clients, RMTs must ensure clients are notified (directly or through a representative) when they are leaving a practice or if the practice is closing/being sold to assist with the transfer of care, and ensure clients know what will be done with their records and how to access copies.

Client records and personal health information cannot be sold as an asset of a practice, even upon an RMT’s death.

If you have further questions about record keeping after reviewing this guide, please contact CMTO’s Practice Specialist at practicespecialist@cmto.com or by phone at 416-489-2626/1-800-465-1933 extension 4124.

Legislation and Regulations

• General Regulation made under the Massage Therapy Act, 1991
• Personal Health Information Protection Act, 2004

Related Standard of Practice

• Fees and Billing