It is the professional responsibility of all massage or manual osteopathic therapists to maintain client records for at least 10 years after the client’s last treatment, longer if the client was a minor at the time of their last treatment. CMMOTA has written policy on what client records are to include, and the time frame in which treatment notes are to be completed by the therapist. These are contained in CMMOTA’s Client Records, Charting, and Treatment Notes Policy.
Failure to maintain proper client records is considered to be professional misconduct and would result in disciplinary action if discovered and reported.
Documentation is incredibly important on several fronts. First, it is the official record of your professional interaction with a client, starting with their initial intake forms, and followed by treatment notes for every treatment which you have provided. Documentation must also include all forms related to health insurance billing if you are providing direct billing services for your clients.
Second, documentation is important should you ever be audited by a health insurance company. Failure to produce a client’s record, including treatment records for treatments which were billed to the insurance company may result in the insurance company reversing coverage, meaning that you would be liable for repayment of benefits. We are aware of instances where the failure to produce records has resulted in civil action on behalf of the insurance provider to recoup what are then considered to be fraudulent claims.
Finally, documentation is important because your treatment notes may end up serving as evidence in court. Here are a couple of examples. Treatment notes have been used in court cases to provide evidence for signs of physical abuse. Treatment notes have also been used in court cases to provide evidence related to injuries that were sustained as a result of a motor vehicle collision, and other accidents which clients have experienced. Remember that your professional written documentation of treatments which you have provided are the official record of your professional interaction with a client and can be requested by court order.
If you want to learn more about treatment notes, and ways that you can improve on your documentation techniques we would encourage you to watch the CMMOTA Info Session on SOAP Notes. To learn how to access this informational video please visit https://cmmota.com/how-to-access-past-cmmota-info-sessions/
If you have not been keeping a client record, please change your practice and start immediately. If you need assistance in knowing what to include in your treatment notes, please reach out to the association via email to info@cmmota.com and a member of our team will be happy to assist you.