Standard of Practice: Record Keeping

Patient Outcome

The patient’s health records are maintained, stored, transferred, and disposed of in a way that keeps patient information confidential and secure.

Registered Massage Therapist Outcome

Registered Massage Therapists/Massage Therapists (RMTs/MTs) will prepare accurate and complete patient health records and other documentation.

Requirements

RMTs/MTs must:

1. Ensure, 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 under the Massage Therapy Act, 1991), and the Records and Record Keeping sections of the Professional Misconduct Regulation (Part VIII of the General Regulation under the Massage Therapy Act, 1991).
2. Identify their role and responsibility related to privacy legislation in every practice [such as agent versus health information custodian (HIC)] and ensure those details are reflected in applicable employment or contractual agreements for their practice.
3. Protect the confidentiality of all reports and records, including protection from loss, tampering, interference, or unauthorized use or access. (see also the Standard of Practice: Prevention of and Zero Tolerance for Sexual Abuse).
4. Patient health records must be retained for 10 years after the patient’s last visit, or 10 years after the day the patient turned 18 (if they were under 18 at the time of their visit). Destroying records must only be done after this time, and in a way that maintains patient confidentiality.
5. Provide access to, or a copy of, a patient health record when a request is received from those authorized to access the health record by law, including:
   1. Those designated by CMTO;
   2. Those designated by the Ministry of Health; or
   3. Persons conducting health research, administration or planning after information that could be used to identify individual patients is removed.
6. Transfer patient records when the RMT/MT retires, moves practices or locations, or when otherwise requested by the patient; and
7. Maintain the following records:
   1. A daily appointment record with the name and appointment/treatment time of each patient;
   2. An equipment service record documenting the servicing of equipment used to examine or treat patients;
   3. Financial records for each patient that comply with the Records Regulation; and
   4. Personal health record for each patient that complies with the Records Regulation.
8. Not allow an individual to examine a patient record or access information in it, unless the patient or their authorized representative consent to it, or if it is permitted or required by law.
9. Not falsify records relating to the RMTs/MTs practice; or a patient’s health record.
10. Not sign or issue in the RMT/MT’s professional capacity, a document that the RMT/MT knows or ought to know includes a false or misleading statement.
11. Have a written agreement in place when joining a practice with their employer or the facility operator, setting out the procedures for record handling and storage, and addressing what happens to the records when the RMT/MT ceases to work at that practice, including in cases of termination of employment and the practice closing, relocating or being sold if the RMT/MT is not the health information custodian (HIC).
12. Have a plan in place if the RMT’s/MT’s employment relationship with a practice ends, and the RMT/MT is not the HIC, for the RMT/MT to be given copies or access to patient records.
13. When leaving a facility, share their contact information with the facility prior to changing their practice location.
14. Ensure patients 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 patients know what will be done with their records and how to access copies.
15. Not sell patient records and personal health information as an asset of a practice, even upon an RMT’s/MT’s death.

Bolded terms are found in the Glossary.