2-Hour Class Notes from Rochester Massage Alliance

2. CLASS AGENDA
• Records
• Storage
• Electronic and Paper
• Forms
•
•
•
•
•
Health History Form
New Client Checklist
SOAP notes
Receipts/Superbill
Client Registration
• Communication with Deaf Clients
• Working with Specific Health Issues
• Permission to Contact Physician (or
others)
• When to Ask for Payment
• Keeping track of CE classes
• CE Self-Study

3. CLIENT/PATIENT RECORDS
• Storage – under lock and key – or lock via password if electronic
• Must be retained at least 6 years after the last appointment, or until the patient’s 22nd
birthday (whichever is later)
• Must be retained even after a patient death

4. CLIENT/PATIENT RECORDS
• What do you HAVE to have?
• Health History Form
•
•
How often do you have them complete one?
Do you ask about pins? Implants? Prostheses? Incontinence?
• Record of treatment (SOAP, HATT, back of an envelope…)
• Signed statement to release records prior to release

5. CLIENT/PATIENT RECORDS
• What else SHOULD you have?
• Record of payment
• Copies of any communication you send to client or on behalf of client
• Additional Forms that May be Helpful
• Billing/Superbill
• New Client Checklist
• Client Registration

6. HIPAA & RECORDS
• If you accept insurance your records MUST be kept electronically (either in place of
paper, or in addition).
• There is NO specific format required for electronic records (use pdf, or online records
systems.
• Patient files should be able to be encrypted or password protected BEFORE being sent
through any online function (including email)

7. CONFIDENTIALITY
• Your clients have the right to confidentiality.
• Do not discuss your clients with others in any way that is identifiable.
• Do not approach clients in a public forum without permission. (Some clients do not want
others to know they see any healthcare worker, including massage.)
• Protect your client records.
• Seek permission to leave messages on voicemail.
• Examples…

8. FORMS
• Health History Form
• There are a million variations. Find one that fits you – and includes all pertinent information.
• Examples.
• SOAP Notes
• These don’t have to follow a set standard, but do have to include what your treatment
included.
• Records can be subpoenaed, and clients have a right to copies of their files, so only
include information that you would want your client to see.

9. GREETING YOUR CLIENT
• New Clients
• Health History Form
• New Client Checklist
• New Client Registration
• Continuing Clients
• Has anything changed since their last visit?

10. COMMUNICATION WITH DEAF CLIENTS
• Helpful Signs
• Hello
• How are you?
• I’m fine.
• Where does it hurt?
• More
• Less
• My name is
• Helpful Signs
• Turn over
• Money values (to express
payment due)
• Yes and No
• How can I help you?
• Please fill out this form.
• Helpful Signs
• Would you like to reschedule?
• How is the pressure?
• Does it hurt there?
• What kind of pressure?
•
•
A lot
A little

11. COMMUNICATION WITH DEAF CLIENTS
• Helpful Communication Tools
• Pen & Paper (or whiteboard)
• Placard for them to slide under the door when they are getting on the table
• Determine a way to tell them the session is over. (Tap on the shoulder, for example.)

12. SPECIFIC CLIENT HEALTH ISSUES
• Diabetes
• Epilepsy
• Communicable Disease
• Signs of Abuse (Who is required to report?)
HTTP://OCFS.NY.GOV/MAIN/PREVENTION/FAQS.ASP#MANDATED
• Incontinence
• Others?

13. PERMISSION TO CONTACT OTHERS
• From time to time you may need to or want to speak with a client’s other caregivers or
family members. Although this is rare, you still need to have the client’s permission to
speak to their other healthcare workers, family members, or social workers, etc.
• Get permission in writing. Keep it in their file as long as you keep their record.

14. GETTING PAID
• Ever have a client “forget” their wallet? What did you do?
• Pros and Cons of asking for payment up front:
• Pro: You can deny service if they “forgot” their wallet
• Pro: They don’t have post-massage-brain syndrome when they pay you
• Con: May impact whether or not you receive a tip
• If a client forgets their money, it’s your right to call and remind them. Take a CC payment
over the phone, or give them a stamped envelope to mail you a check.

15. CONTINUING EDUCATION PAPERWORK
• Must attest to 36 hours every triennial period.
• Keep records in case of audit.
• Certificates of courses completed.
• Record of self-study.
• We have created forms for you to track your hours, and to record self-study. They are
under Member Resources on our website.
• 50 minutes of instruction = 1 hour of continuing education.

16. QUESTIONS?
We have answers! (Or will find them for you…)
www.RochesterMassageAlliance.com
info@rochestermassagealliance.com
michelle@rochestermassagealliance.com
Christine@rochestermassagealliance.com