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writinganotherreflectionpaper500.zipCMTO Record Keeping e-Workshop Module One (May 2021).key
CMTO Record Keeping e-Workshop Module One (May 2021).pptx
Record Keeping e-Workshop Module One
This is a web-based workshop which provides an overview of the record keeping requirements for the Massage Therapy profession in Ontario.
The learning content in this workshop is designed to help participants learn how to integrate applicable legislation and regulations into their record keeping practices. Participants will also learn how to develop effective documentation and how to apply the principles of professionalism to the record keeping process.
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Workshop Description
Developing Knowledge and Competence for Practice
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This Workshop helps participants to develop the following STRiVE program career-span competencies:
Communicate effectively
Comply with legal requirements
Maintain comprehensive records
Use an evidence-informed approach to practice
Practice in a self-reflective manner
Introduction - Exploring the importance of creating and maintaining records
Legislative Hierarchy - Reviewing the professional regulations for the Massage Therapy profession
Principles of Professionalism - Identifying the principles associated with record keeping
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Module Content
After completing this module, participants will be able to:
Recall the reasons for maintaining records
Identify professional regulations for the Massage Therapy profession
Identify the professional principles associated with record keeping practices
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Learning Objectives
An Introduction to Record Keeping Exploring the importance of creating and maintaining records.
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Proper record keeping is essential to the practice of Massage Therapy.
Massage Therapists have a duty to the client to make and maintain proper records of any professional interaction.
There are 4 primary reasons for creating and maintaining client health records:
It assists the Massage Therapist in recalling details of the client's history, condition, and the treatment provided.
It assists the continuity of care if colleagues or a locum are called upon to treat the client.
It provides a record for medical legal purposes when the client requires a report relating to the illness or injury treated.
It provides a record of events for the Massage Therapist in the event subsequent inquiries relating to the treatment are made by insurers or a complaint against the Massage Therapist is submitted to the College.
The Hierarchy of Legislation Reviewing the professional regulations for the Massage Therapy profession.
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There are three levels of government in Canada with corresponding legislation:
Federal – Has the highest authority. Examples of federal legislation are the Charter of Rights and Freedoms and the Criminal Code.
Provincial – This legislation directly governs the practice of Massage Therapy in Ontario. Examples of provincial legislation include the Regulated Health Professions Act, 1991, the Massage Therapy Act, 1991, the Health Care Consent Act, 1996, and the Personal Health Information Protection Act, 2004.
Municipal – Each municipality in Ontario has certain by-law requirements that must be adhered to when living/working within that municipality. An example of this would be zoning by-laws.
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The Regulated Health Professions Act, 1991 (RHPA) is the overarching provincial legislation which governs all regulated health professions in Ontario.
The dominant purpose for this legislation is protection of the public interest. The RHPA contains:
“features designed to ensure that the Councils that govern Colleges and their committees will govern themselves in the public interest. The result will be a more open and accountable system of self-governance.” (Steinecke, A Complete Guide to the RHPA)
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The Regulated Health Professions Act, 1991 gives the colleges the authority to make regulations:
Regulations are methods of providing specific powers and duties to a college.
Regulations deal with matters of broader public concern.
Matters are put in regulations because:
The provisions are too detailed for inclusion in the statute itself.
The content of the provisions will vary from profession to profession.
Frequent amendments to the provisions are likely to occur (regulations can be changed without going to the legislature).
There is a formal process for drafting and approving regulations, and once they are approved by the College Council and the provincial government, health professionals are required to comply with the regulations as components of the Act(s).
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The Massage Therapy Act, 1991 (MTA) is the health profession specific act for Massage Therapists in Ontario.
Important components of the MTA include:
Scope of Practice.
Restricted Titles.
Composition of Council.
The MTA also establishes regulations for:
Certification examinations, advertising, notice of meetings and hearings, records.
Professional Misconduct and Quality Assurance Program.
Registration requirements.
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In addition to legislation, CMTO provides the following regulations to Massage Therapists to guide their compliance with legislation:
By-laws
Standards of Practice
Policies
Position statements
Practice Resources
Guidelines
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By-Laws:
The Council may make By-laws relating to the administrative and internal affairs of the College.
Examples of this would be election of council members, qualifications and terms of office of council members, banking and finance.
Standards of Practice:
Describe the expectations for how Massage Therapy is applied in practice.
Establish the expectations for all Massage Therapists regardless of their role, job description or area of practice.
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Policies:
Articulate the Council’s opinion on specific issues relating to the practice of Massage Therapy.
Provide a broader explanation of practice issues found in legalized format of the corresponding regulation.
Position Statements:
Provide the collective opinion of the College’s Council relating to practice issues that may or may not be covered by a regulation or policy.
Often developed in response to a Registrant’s questions in order to provide a framework within which practice decisions can be made.
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Practice Resources:
Address questions that registrants or clients may have about
particular practice-related issues.
Guidelines:
Provide a detailed description of the way in which a policy or
position is translated into practice.
Provide information about practice issues that are not outlined
within legislation.
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Understanding these legislative requirements and the legislative hierarchy is essential to understanding your responsibilities as a Massage Therapist.
You can find direct links to all applicable legislation and regulations published on the College website. Take a moment to find the links to legislation and regulations here.
Professionalism in Practice Identifying the principles associated with record keeping.
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Professional principles are established by legislation and regulations.
According to the regulations for a Massage Therapy practice, record keeping practices must be consistent with the following professional principles:
All information relating to Massage Therapy services provided to clients must be maintained confidentially.
The information contained in a health record belongs to the client and can only be released with the client’s consent unless access to the information is permitted according to applicable legislation.
The client has a right to access the information contained in his/her health record.
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In order to build a more comprehensive understanding of how professional regulations establish principles within a practice, take some time to review CMTO’s Code of Ethics document.
The Code of Ethics document for the Massage Therapy profession informs Massage Therapists how to approach all matters related to practice.
Massage Therapists are responsible for fulfilling the commitment to upholding the principles at all times whenever they practise Massage Therapy.
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The Code of Ethics consists of four ethical principles that require Massage Therapists to conduct their practice in a manner that will:
1. Benefit Clients and Serve Their Best Interests
2. Treat all Clients with Respect and Dignity
3. Not Harm Clients
4. Be Responsible and Accountable
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More specifically, Principle 4 establishes that Massage Therapists must be responsible and accountable.
Here are some examples of how this Principle can be incorporated into record keeping practices:
Maintaining clear, legible and comprehensive client and business records.
Using electronic communication, social media and other forms of technology responsibly.
Refusing to participate in any kind of fraud, including fraudulent billing practices.
CMTO Record Keeping Workshop Module Four - June 2021.pptx
CMTO Record Keeping Workshop Module Four
After completing this module, participants will be able to:
Identify the necessary components of a Massage Therapy treatment plan as established by regulations; and,
Recall the requirements for recording information related to treatments and treatment planning;
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Learning Objectives
Treatment Planning
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The Massage Therapy Act (1991), a client health record must include:
‘A copy of any treatment plan.’
‘Particulars of the treatment applied at each of the client’s visits to the registrant and the name of the registrant who applied the treatment.’
Once the client health history intake and assessment processes are completed, it is the Massage Therapist’s responsibility to determine if Massage Therapy is indicated for the client.
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Communication / Public Health Standard of Practice # 9 states:
‘If there is a contraindication to massage therapy, you refer the client to another health care professional or that you modify the treatment so that the client is not put at risk.’
As regulated health care professionals, Massage Therapists must be able to use professional judgement to recognize the limits of Massage Therapy care.
A Massage Therapist’s first priority should be the health and well-being of clients. When it is in the best interests of the client’s health and well-being to modify a treatment plan, or stop a treatment plan and refer to another health care professional; the Massage Therapist must do so.
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After the initial treatment, if a Massage Therapist determines that on-going Massage Therapy care is indicated, the next steps for the Massage Therapist would be to:
- create a treatment plan;
- provide the recommendations for additional treatments to the client and fully explain the treatment plan; and,
- provide the client with the opportunity to ask questions about the proposed treatment plan.
According to Communication / Public Health Standard # 10:
- the treatment plan must be suitable to the Scope of Practice and consistent with College policies; and,
- any changes to the client’s consent are obtained before each treatment and are followed.
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According to Standard # 10, a treatment plan must include:
- goals;
- type and focus of treatment;
- areas of the body to be treated;
- anticipated frequency and duration of treatments;
- anticipated client responses to treatment;
- schedule for reassessment of the client’s condition; and,
- recommended remedial exercises or hydrotherapy.
Massage Therapists must record all of these details into the client health record.
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Massage Therapists are also responsible for making changes to a treatment plan if:
- The client expresses their wishes for change;
- There are changes to the client’s health status or physical condition;
- The Massage Therapist notices a change to the client’s condition that requires a change; or,
- The Massage Therapist notices a lack of response to treatment.
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If a change to a treatment plan is required, Massage Therapists must ensure:
- that the information conveyed to the client includes what the changes to the treatment plan will be, and why the changes are necessary; and,
- that consent is obtained for all changes to the treatment plan, and that consent is documented into the client health record.
Clients must be provided with the opportunity to consent to changes in the treatment plan before any of those changes are implemented into treatments. Consent must be documented into the client record no later than 24 hours after the consent was obtained.
Treatment plans are not meant to be static. Plans should be flexible and adaptable based on each client’s situation.
It is the Massage Therapists responsibility to recognize when a change to a treatment plan is necessary.
On-going Treatment Notes
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After a Massage Therapist provides a treatment, details of that treatment need to be recorded into the client health record no later than 24 hours after the appointment time.
Communication / Public Health Standard # 14 states that client health records must contain:
- the date, time and duration of any treatment;
- the fee(s) for that treatment;
- results from any assessments used by the therapist;
- a summary of the techniques that were used;
- the areas that were treated;
- client reactions and feedback from treatment; and,
- that informed consent was obtained from the client or substitute decision-maker.
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It is important for Massage Therapists to understand their responsibilities to maintaining on-going treatment notes for every client.
The reasons for maintaining accurate and legible on-going treatment notes include:
- it is necessary to ensure the accurate and consistent continuation of a treatment plan;
- it is necessary to ensure the accurate and consistent continuation of care for each client from one Massage Therapist to another; and,
- it provides a record of the Massage Therapist’s care which demonstrates their accountability.
CMTO Record Keeping Workshop Module Three (June 2021).pptx
CMTO Record Keeping Workshop Module Three
After completing this module, participants will be able to:
Identify the regulations that outline the responsibilities for documenting assessment and / or reassessment information; and,
Recall the requirements for conducting assessments and reassessments.
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Learning Objectives
Assessment
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The Massage Therapy Act, 1991 establishes that health records must contain:
‘Particulars of every examination performed by the registrant and particulars of every clinical finding and assessment made by the registrant.’
Therefore, RMTs must document the results of every assessment(s) and reassessment(s) into the client’s health record in order to comply with the Act. The results of assessment(s) and reassessment(s) should be recorded into a client’s record within 24 hours after the appointment time.
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When it comes to choosing the types of assessments / reassessments to use, RMTs should refer to Standard of Practice # 8.
Communication / Public Health Standard of Practice # 8 establishes that it is a Massage Therapist’s responsibility to:
‘Determine the client’s condition by using history and observation to formulate a clinical impression and conduct (if required) a differential assessment and / or re-assessment to confirm the clinical impression.’
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According to Standard # 8, an assessment must include an examination of any of the following when indicated:
- any acute / sub-acute or chronic conditions and / or any acute or chronic pain so that it is described as to location, type, duration, origin, pattern, triggering
- phenomena, intensity, quality
- central nervous system lesions and / or conditions
- range of motion of joints and muscles (active, passive and resisted) without forcing movements beyond the client’s current abilities
- flexibility of the soft tissues so that you can identify any limitations to movement
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Additional responsibilities established by Standard # 8 are:
- performing assessments bilaterally
- identifying any physical conditions that are treatable by Massage Therapy
- referring the client to another health care professional for conditions when indicated, for example if the client is experiencing severe, unremitting pain or severe pain with no history of injury
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According to Standard of Practice # 8, RMTs must ensure that a thorough assessment of the client is completed in order to determine the indications for treatment and to identify any conditions which may require referral to another health care practitioner.
The requirements of this Standard also support RMTs to establish whether they have the knowledge and competence to provide safe and ethical care, and whether the treatment is be suitable to the Scope of Practice for Massage Therapy.
RMTs must conduct assessments in order to design safe treatments; and they must conduct reassessments to determine whether the treatment was effective.
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According to Part VIII, s. 26 of the regulations in the Massage Therapy Act, 1991, it is considered professional misconduct when an RMT:
- Treats or attempts to treat a condition beyond their level of competence.
- Fails to refer a client to a qualified medical practitioner when they’ve recognized or failed to recognize a condition which requires medical examination.
- Fails to maintain records as required.
- Falsifies a record relating to their practice.
Therefore, conducting assessments and reassessments, and documenting the results of into client health records are important practices that support compliance to the Massage Therapy Act, 1991.
CMTO Record Keeping Workshop Module Two (June 2021).pptx
CMTO Record Keeping Workshop Module Two
Client Health Record – creating and maintaining client records
Health History – collecting relevant health information
Consent – the requirements for documenting informed consent
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Module Content
After completing this module, participants will be able to:
Identify the required components of a client health record
Identify the requirements for collecting health history information
Identify the requirements for documenting informed consent
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Learning Objectives
Client Health Record Creating and Maintaining Client Records
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The Massage Therapy Act, 1991 establishes that Massage Therapists must create and maintain certain records.
These records include:
Daily appointment records – these records must include the name of each client and the date / time of their appointment.
Financial records – the records must include the particulars of the treatment rendered, the fee charged for the service provided, and a copy or record of the receipt issued for payment of the service provided.
Client health records – these records must include specific information about the client, for example their name and full address, relevant medical history, name and address of primary care physician, history of massage therapy, etc.
Equipment Maintenance records – more information about equipment maintenance records is available in Module Seven.
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The Act also establishes that:
- records may be kept on paper, electronic format or optical storage system;
- all information within a client file must be maintained in a confidential manner;
- only an authorized person may have access to the client health record (more on this will be discussed in Module 6);
- every client health record shall be retained for at least 10 years following the client’s last visit, or if the client was less then 18 years old, 10 years from their 18th birthday; and,
- information must be collected before the initial treatment begins; and that updates to information must be collected every year after the date of the last year – at a minimum.
Health History Collecting relevant health information
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The Communication/Public Health Standard 6 indicates what the College deems to be the minimum amount of information that should be collected from every client.
Health history information must be obtained from the client so that the Massage Therapist can identify indications for treatment; or, possible contraindications to treatment.
By having complete and up to date client information, the Massage Therapist is more capable of delivering safe and effective care for each client.
Health history information can be obtained in written format (health history form) or verbally through the interview process.
If a Massage Therapist collects health history information verbally, then they must ensure that all of the screening questions asked are recorded into the client’s file; and, that all answers provided by the client are also recorded into the record.
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Health history information to be collected and recorded by the Massage Therapist includes:
- date on which health history was taken or updated;
- general health status;
- client name;
- address;
- date of birth;
- telephone number;
- occupation;
- source of referral;
- timing and nature of injuries or accidents;
- timing and nature of surgical procedures;
- history of Massage Therapy;
- primary complaint; and,
- location and nature of soft tissue and or joint discomfort.
Consent The requirements for documenting informed consent
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According to the Health Care Consent Act, 1996 (‘HCCA’), healthcare professionals must obtain informed consent in a manner that is consistent with the following principles:
• The consent must relate to the treatment;
• The consent must be informed;
• The consent must be given voluntarily; and,
• The consent must not be obtained through misrepresentation or fraud. 1996, c. 2, Sched. A, s. 11 (1).
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The HCCA also distinguishes between consent and informed consent. A consent to treatment is informed if:
• The person received the information about the proposed treatment plan that a reasonable person in the same circumstances would require in order to make a decision about the treatment (for example nature and purpose of treatment); and,
• The person received responses to his or her requests for additional information about those matters. 1996, c. 2, Sched. A, s. 11 (2).
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When explaining the proposed treatment plan for informed consent, the Massage Therapist must explain:
the nature of the treatment;
the expected benefits of the treatment;
the material risks and side effects of the treatment proposed;
any alternative options; and,
the likely consequences of not having the treatment.
Informed consent can only be obtained after the Massage Therapist has discussed the proposed treatment plan and the client’s questions have been answered.
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One of the professional responsibilities of Massage Therapists is to determine if the client has the capacity to give informed consent.
According to the HCCA, a person has capacity if they are able to understand the information that is relevant to making a decision about the treatment; and, the person is able to appreciate the reasonably foreseeable consequences of a decision or lack of decision. 1996, c. 2, Sched. A, s. 4 (1).
In Ontario, the ability to give consent for personal health care is related to capacity, not age. Therefore, Massage Therapists must use the above criteria to determine if their client has the appropriate capacity regarding the proposed treatment.
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If the Massage Therapist determines that the client does not have capacity, they are required to postpone treatment until a Substitute Decision Maker can be appointed to make the decision on the client’s behalf.
The HCCA stipulates that if a person is incapable with respect to a treatment, consent may be given or refused on his or her behalf by a person described in the following list:
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1. The incapable person’s guardian.
2. The incapable person’s attorney for personal care.
3. The incapable person’s representative appointed by the Board under section 33.
4. The incapable person’s spouse or partner.
5. A child or parent of the incapable person.
6. A parent of the incapable person who has only a right of access. 7. A brother or sister of the incapable person.
8. Any other relative of the incapable person. 1996, c. 2, Sched. A, s. 20 (1).
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CMTO Standard of Practice # 7 – Consent provides additional guidance to Massage Therapists for the informed consent process. In order to fulfill their responsibilities to Standard # 7, Massage Therapists must:
- Obtain informed consent before the beginning of the assessment/reassessment and / or treatment; and,
- Record that informed consent was obtained in the client’s clinical record as soon as possible, no later than 24 hours after the appointment time.
In accordance with the Massage Therapy Act, 1991, it is considered an act of professional misconduct to do anything to a client for a therapeutic, preventative, palliative, cosmetic or other health-related purpose in a situation without obtaining informed consent beforehand.
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In 2017, the Protecting Patients Act, 2017 was passed into legislation. This resulted in important amendments to the Regulated Health Professions Act, 1991.
According to these amendments, touching specific areas of a patient’s body in a manner that is perceived as sexual in nature is considered as sexual abuse. The areas of the body are defined in the Act as the breast, buttock, anal and genital areas.
Given that Massage Therapy can involve clinically indicated touching of the breast or buttock areas within a treatment; CMTO developed and implemented Standards of Practice to support RMTs in fulfilling their duties to practise in a manner that is consistent with the amended legislation.
Please take a moment to review Part B of the Standards of Practice for Maintaining Professional Boundaries and Preventing Sexual Abuse.
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Standard B1: Treatment of Sensitive Areas of the Body provides important steps that Massage Therapists must complete when the assessment or treatment of a sensitive area is indicated in a Massage Therapy treatment plan.
Take some time to review Standard B1 on pages 7 to 12 here.
When a Massage Therapist believes that the assessment or treatment of a sensitive area is indicated for a treatment plan; the RMT must obtain informed consent in written form and place the signed form into the client’s health record.
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Shortly after the release of the Standards of Practice for Maintaining Professional Boundaries and Preventing Sexual Abuse, the College published helpful FAQ documents for clients and for Massage Therapists.
Please feel free to take some time to review these additional resources and use them in your practice. You can find the FAQ for clients here, and for Massage Therapists here.
In addition to the FAQ’s, the College also provides RMT with a form template for obtaining written consent to assess / treat a sensitive area. You can find that form template here – click on the Continuing Education / Quality Assurance tab.
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In summary, Massage Therapists as regulated health care practitioners are required to obtain informed consent before proceeding with assessment, treatment or reassessment processes.
Obtaining informed consent is required at every appointment; and, whenever a treatment plan changes.
When informed consent is obtained verbally, the Massage Therapist must record that consent was obtained into the client’s health record.
Whenever the assessment or treatment of a sensitive area is indicated in a Massage Therapy treatment plan, the Massage Therapist must obtain informed consent in written form before the treatment begins at every appointment, with the exception of the gluteal area. The exception for the gluteal area is described on page 11 of the published Standards document.
