500 words due by 16 hrs

CMTO Record Keeping Workshop

Module Seven

After completing this module, participants will be able to:

o Identify the general requirements for record keeping in a massage therapy practice;

o Recall the professional misconduct regulations related to record keeping.

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Learning Objectives

General Requirements

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The general requirements of record keeping for a Massage Therapy practice include:

 Creating and maintaining the required records for a massage therapy practice in a manner that is consistent with applicable regulations;

 Organizing custody, control and security of client information; and,

 Ensuring proper storage and destruction of records in accordance with applicable regulations.

Creating and Maintaining the Required Records for a Massage Therapy Practice

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According to the Massage Therapy Act (1991), Massage Therapists are required to create and maintain 4 types of records as a part of a practice:

 An appointment record;

 Financial records;

 Client health records; and,

 Equipment records.

The Massage Therapy Act, 1991 and the Standards of Practice also establish the types of information that each record must contain.

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What are ‘equipment service records’?

According to the Massage Therapy Act (1991): ‘an equipment record shall be kept that sets out the servicing of any equipment used to examine or treat clients, or to render any service to clients’

Examples of equipment that are used to provide treatment to clients, or to render services to clients can include:

- Massage Table

- Hydrocollator

- Paraffin wax bath

- Ultrasound / TENS or Laser machines

- Exercise equipment / machines

- Hydrotherapy equipment or facilities

A complete equipment record will include documentation that reflects all equipment is regularly inspected and serviced or repaired when necessary.

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Standard of Practice # 2 establishes that MTs must create a fee schedule and a cancellation policy.

The fee schedule and cancellation policy must also be posted in a manner that is accessible to clients.

Standard of Practice # 14 requires MTs to record fees for treatment into the client health record.

Whenever a MT charges a fee that is different from the posted fee rate, the MT must document the fee rate charged as well as the reasons for the change in fees into the client health record.

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The duties of record keeping require Massage Therapists to ensure that:

 All required records are established and maintained wherever they choose to conduct a practice;

 All records are complete and that the contents include the required information as outlined in the Massage Therapy Act (1991) and the Standards of Practice;

 All records are kept in an organized and legible manner so that information is easy to find and understand; and,

 All information contained in the records is accurate.

Organizing Custody, Control and Security of Client Information.

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Prior to starting a new practice or joining an existing practice, Massage Therapists should establish whether they will be fulfilling the role of a ‘Health Information Custodian’ (HIC) or whether they will be acting as an ‘Agent’ to a HIC in the new practice.

The HIC is responsible for: - Creating and maintaining records for a massage therapy practice; - Creating a privacy policy / statement for the practice; - Storing records in a secure and confidential manner; - Controlling access to client information; - Responding to all requests for information or copies of records; - Reporting privacy breaches as required by PHIPA (2004); - Maintaining custody over client health records for the mandatory storage period;

and, - Destroying the records confidentially when the mandatory storage period has

expired.

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An ‘Agent’ to a Health Information Custodian is responsible for:

- Creating and maintaining records for a massage therapy practice;

- Following the guidelines established by the privacy policy / statement for the practice;

- Ensuring records are stored in a secure and confidential manner;

- Forwarding all requests for information or copies of records to the HIC; and,

- Reporting privacy breaches to the HIC.

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As healthcare practitioners, RMTs should always be provided with access to records they have worked with; however, they are only entitled to use the information for reasons established by privacy legislation.

When a Massage Therapist departs from a practice where they were an Agent to a HIC, they are not entitled to make or take copies of client health records without first obtaining consent from the client.

In cases where an RMT departs from a practice where they were an ‘Agent’, they can choose to obtain client consent to make and take copies of records with them; or, they can organize a written agreement with the HIC which would allow them to obtain access to the records if required for medical or legal reasons.

When a Massage Therapist departs from a practice where they were the HIC, they can choose to take the records with them; or, transfer the custody of the records to another HIC. The MT must notify clients of any changes to contact information for the HIC.

When a Massage Therapist as a HIC retires from practice, they can choose to continue maintaining custody and control over the records until the mandatory storage period has expired; or transfer the custody to another eligible HIC.

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If a Massage Therapist dies before retiring from practice, their estate may elect to store the records according to privacy and confidentiality regulations; or, they can choose to transfer the custody of the records to another eligible HIC.

The College of Massage Therapists of Ontario cannot assume custody of client health records under any circumstance, including upon the unexpected death of a MT.

Ensuring Proper Storage and Destruction of Records in Accordance with Applicable

Regulations.

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The CMTO Policy for the Maintenance of Client Records establishes that client health records must be stored for 10 years after the date of the client’s last visit. The policy further states that in cases where clients are under the age of 18 years at the time of treatment, Massage Therapists must store those records for 10 years past the date of the client’s 18th birthday.

The Policy requires Massage Therapists to adhere to the following principles when maintaining records:

 All information relating to the Massage Therapy services provided to a client is collected and maintained confidentially;

 That all personal information collected from a client belongs to the client and can only be released / disclosed with the client’s consent as required by law; and,

 That the client has the right to access their information from a health record.

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Records can be created and maintained in paper or electronic format. No matter what format a Massage Therapist chooses, the record keeping system must ensure that records are secure from loss, tampering, interference or unauthorized access / use.

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Once the mandatory storage period has expired, HICs are responsible for destroying records in a confidential manner.

The Office of the Information and Privacy Commissioner for Ontario (IPCO) recommends that records are destroyed in a responsible and secure manner.

The IPCO Fact Sheet entitled ‘Secure Destruction of Personal Information’ outlines the recommended best practices for the secure destruction of records that contain personal information. Take a moment to review the ‘Fact Sheet’ here.

Professional Misconduct Regulations Related to Record Keeping

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Section 26 (2) of the Massage Therapy Act (1991) outlines the professional misconduct charges specifically related to record keeping:

 Allowing any person to examine a client health record or giving any information, copy or thing from a client health record to any person except as required or allowed by law;

 Failing to provide copies from a client health record for which the member has primary responsibility, as required by the regulations under the Act;

 Failing to make arrangements with a client for the transfer of the client’s records in the care of the member:

When the member retires from practice;

When the member changes office location and the client requests that the records be transferred; or,

When requested to do so by the client.

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 Failing to keep records as required;

 Falsifying a record relating to the member’s practice;

 Failing, without a reasonable cause, to provide a report or certificate relating to an examination or treatment performed by the member, within a reasonable time, to the client or the client’s authorized representative has requested such a report or certificate;

 Signing or issuing, in the member’s professional capacity, a document that the member knows to contain false or misleading statements.