A SOLID CLIENT RECORD REALLY DOES MATTER WHEN CONSIDERING HEALTH OUTCOMES IN YOUR PRACTICE

 

One of the most important aspect of client record keeping for massage therapy is the ability to document measurable health outcomes as a result of care.  As Massage Therapists, our value is tied to effectiveness—if we can chart progress in the patient’s condition, primary care providers are more likely to refer their patients to us.  Simple 0-10 scales that measure pain, stress and activities of daily living are quite sufficient to substantiate a client’s condition and massage’s effect on his life. This information becomes more meaningful when graphed over time.

A quick glance at a graph illustrating a decrease in pain or an increase in function over the course of massage therapy sessions validates including a medical massage therapist on a pain-management team. It also justifies the expense for clients who pay for massage out-of-pocket.

Documenting patient satisfaction is the second-most-important function of health record keeping. In many cases, we rely on clients to ask for referrals or prescriptions for massage therapy. People who are dissatisfied with conventional medicine seek massage therapy on their own because it works and it feels good.

Massage therapy can play a very important role in integrative health care, and is commonly used to boost patient satisfaction in hospitals and clinics.   Key Components Charting a massage therapy session can be fast and easy.

Electronic health record systems prompt the necessary information to gather, and much of it can be done with the touch of a button. Basic health information required for wellness care includes:

• Client name
• Health history
• Current health information/changes in client’s presentation or condition
• Date of service and duration of session
• All treatments provided
• Location or body parts where treatment was applied

Records must be signed, dated and completed in 24 hours, or include the date completed if other than the date of service. Records must be retained for seven years, and kept secure and confidential.   More Components Additional information is necessary when communicating with other members of a health care team or submitting bills for third-party reimbursement. In order to demonstrate meaningful outcomes, symptoms must be measured.

Chart the following information to enhance your success on health care teams and establish value with patients and physicians alike:

• 0-10 measures for pain, stress and activities of daily living
• Graph results over time
• Identify functional limitations
• Set goals based on activities of daily living
• Chart functional outcomes
• Provide self-care education and chart the client’s follow-through

Documented Improvement

Despite the challenges, being an active part of an integrative health care team is exciting. Patients readily acknowledge our contributions, and the medical staff sees the results of our work through patients’ improvement, as documented in our health records.

It is important to interact as a health care provider, record our findings on paper or electronically, and document the benefits of massage therapy.

Look at your Association record requirements and consider these in a very practical sense – how can we utilise these to better document our patient care, treatments and progress. Client Records – Practitioner Checklist

Author: Diana L. Thompson, RMT 2016