RECORD KEEPING FOR SHORT DURATION MASSAGES

(Corporate Chair Massage, Event Sports Massage, Free Give-Away Massage & More)

By Robbin Blake, WSMTA Government Relations Director

Since July 30, 2017, regulations have been in effect for massage therapists, to include record keeping.  If done well, the paperwork needed for shorter duration massage situations does not need to be time consuming or complicated.

We are required to maintain records for all massage performed, regardless of venue or duration.  The new rule can be found by clicking on this link: https://app.leg.wa.gov/wac/default.aspx?cite=246-830-565.  The record keeping WAC has flexibility in what information is required for charting depending on the type of massage performed.  Here is the opening section of the WAC:

(1) A massage therapist providing professional services to a client or patient must document services provided. Documentation should be appropriate to the venue, the type and complexity of those services and, when applicable, in sufficient detail to support and enable anticipated continuity of care. 

(a) Client or patient name and contact information or name and contact information of a parent or guardian if a client or patient is a minor;

(b) Age of client or patient;

(c) Health history sufficient to ascertain if there are cautions or contraindications to safe application of massage therapy, and an update of the current health status at each session;

(d) Date massage therapy is provided and the duration of treatment;

(e) The types of techniques and modalities applied;

(f) The location or areas of the body that received massage therapy;

(g) Written consent to treat;

(h) If breast massage is performed, an additional written consent to treat per WAC 246-830-555, and documentation of a therapeutic rationale;

(i) If breast massage of the nipples and areolas are involved, documentation of the prescription or referral per WAC 246-830-555 (3)(a), or an additional written consent to treat per WAC 246-830-555 (3)(b);

(j) Documentation of any written consent or any modification in coverage and draping as required by WAC 246-830-560; and

If you don't do breast massage or undrape the breasts/gluteal cleft area in these short massages, then you can put aside section (h), (i) and (j) from above.

Before you roll your eyes at what is listed above, the next section shows how to make it simple.

The key to making the record keeping easy, is to:  a) have it mostly preprinted out in advance and b) have the client/patient fill in the paperwork for you as much as possible.

Included at the end of this article is a sample record that you can modify to fit your own needs.  It and versions of it has been used at a variety of events for many years.  Here are suggestions on what you can do to adapt the form and make it more useful to you based on your own situation

• Company Name -- There isn't much space on this form, so unless you have a small, horizontal logo, considering just including your business name.

• Event Name -- If knowing which event/corporate client a client record is associated with, then include the event name/corporate client on the document.  If you don't care and want to use the date or only have one gig, then don't include it. 
• • Events that change constantly -- if you work numerous different events throughout the year, you can choose to handwrite the event out so that you can have form pads printed out in bulk and save money from having to throw away unused forms that you've pre-printed out for an event with the event name on it but never used.
  • Repeating events -- If you go to the same location or only have several events/locations that you work, just leave it off and go by date.

    
    

• LMT -- If there are multiple LMTs working a gig, then require each therapist to print their name since signatures are not necessarily identifiable.  If you run your own business and it's only you, leave it off.
  
  
• Name and Contact Information -- Name, Phone, Address, and City/State/Zip are listed on this form, but the WAC only states "name and contact information".  "Contact information" is up for debate on what this means.  It could be interpreted to mean just phone number, or just email, or just street address.  It's up to you to decide what to do.  If you want to cover all bases for liability reasons (or to follow up in case of any payment issues), then ask for all of it.
  
  
• Age -- Required.
  
  
• Intake -- "Do you currently have any health issues that could affect today's massage?"  Most clients/patients won't know.  You may need to ask them more specific questions based on what type of venue you are in and the event you are doing.  If possible, have the receptionist ask the client to put down as much information as possible, or have the LMT ask questions while taking the client back, or while the client is getting ready to get on the table/chair.  Or, you can create a large print document that is easily readable, that stays at the front desk, telling clients/patients to indicate on the form if they have any of the listed conditions.
  
  
• List the body areas you would like to have massaged --
• • Smaller volume events -- if you don't have a large volume of clients registering at the same time, the form can ask them to list out the body areas they want massaged.  Most people will put legs, arms, etc.  If you need to be more specific, in case you might see them again, then go back and write in more specific details, but in general, have the client list the body areas. 
  • Higher volume events -- Eliminate the handwriting and include the small anterior/posterior SOAP chart body on your form instead.  Ask them to circle the body areas. To create space for the body graphics, move the signatures to the backside of the form.  Just know, it's been our experience that clients often get anterior and posterior legs confused when they circle legs, so you need to clarify this with the client before the massage.  However, using preprinted bodies saves times compared to writing out parts.  Also, clients can get more specific about the areas they want worked on.
• Massage techniques used --  If you do only one or two techniques over and over, list them.  If you do more than several, then list them and circle those that apply.
  
  
• Disclaimer/written consent to treat -- Put whatever disclaimer/consent here that you want
  
  
• Payment Policies:  If you accept checks, you might want to state your insufficient fee policy.  Put any payment policy here that you want.
  
  
• Payment Reconciliation:  Depending on how sophisticated you are with payment, you may want to leave all of these payment options, or take most away.  If you work larger events with multiple LMTs, this line can help you to reconcile the money collected.  The numbers at the right end of the line are number of minutes of this massage.  You could put dollar amount here, but somewhere on this document the duration of the massage has to go.  Since generally the same price is always charged per period of time (e.g., $17 for 15 minutes), unless you're charging different prices for the same number of minutes, you don't need to include price because you know the price based on the minutes of the massage.  Also, short duration massage is often done in set amounts of time, so only list what your options are and circle the correct number.  This can either be done by the client, or the receptionist if it's a larger event, or the therapist.  But generally, whomever is collecting money and whomever is doing the massage should make sure that the number of minutes is accurate as generally this is how LMTs get reimbursed for their time if they are contractors (and clients don't like to be shorted on their time).
  
  
• Parent/Guardian Permission: have the guardian fill this section out.
  
  
• Extra space on back.  If you have any kind of draping exceptions -- often men take off their  shirts at sporting events -- you can put a quick statement about the WAC requirements on breast draping and a signature line.  You can make a statement about this line being available for men only as only men can expose their chests in public without consequences (in most places).

Our suggestion is to print out your forms and try them at several events first and then change anything that doesn't work before you go to a printer (if you have high enough volume) and ask them to make your form into form pads.  This way, you're not stuck with a lot of forms that don't quite work that you have invested a bit of money into.

 To see the Event SOAP sample, click here.