Do SOAP notes belong to the I.C. or the spa owner?

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Permalink Reply by rudy m smith on January 8, 2010 at 12:50pm

Interesting - I wonder if the powers to be realize how (come and go) most massage therapy establishments are. Meaning not many succeed and stay in business long enough to comply with the requirements Massachusetts calls for. I wonder if the state thinks spas and other places that use massage therapists have the staying power of a hospital? There are far too many here today gone to Maui start ups in the business. While massage therapists are great with people most tend to be very weak on the business end of things thus the high failure rate/drop rate within the profession.

Jeanne Riley said:

I'm not sure what state you are from but perhaps this will help. Massachusetts recently became state regulated and has newly defined rules and regulations defined.

In Massachusetts state regulations for Massage Therapists indicate LMT's are required to maintain documentation for each client session (see clip 269 CMR 5.03 below). Requirements for establishments state all client records be kept onsite for a minimum of 7 or 9 years. (see clip 269 CMR 6.06 below.) I interpret this to mean the documentation is the property of the LMT but must be stored at the location the service was provided. The regulations do not state that copies can not be maintained elsewhere as well.

I work at two locations as an independant contractor. At one location there is a well established proceedure for shared client file storage and maintenance and as such I do not feel the need to keep my own copies. At the second location I am responsible for maintaining my own client records and while I keep them onsite in the event that they are needed, the owner does not ever receive them. They are kept in a secure box. In that case since I am ultimately responsible for them, I feel it necessary to maintain a separate but secure backup copy.

I hope that helps. Read on for clips from the MA State Web site.


269 CMR 5.00: Code Of Professional Ethics & Standards Of Professional Practice
5.03 Standards for Documentation.
(1) The Massage Therapist and client shall agree upon the purpose of the Massage session;
(2) No documentation is required if the Massage session is for general relaxation, given during sports or other kind of events, or given during a public demonstration as in chair Massage, unless the client is under 18 years of age. If the client is less than 18 years of age, the therapist must obtain written permission of either a parent or a guardian for the minor client's receipt of Massage therapy;
(3) If a written plan of treatment is requested or required, the client file shall include the following documentation:
(a) The initial evaluation, which shall include:
1. The client's name, age, and gender;
2. Date of the session;
3. Pertinent medical history, including, but not limited to:
a. Client sensitivities and allergies;
b. Medical diagnoses, if available, and the source of the diagnosis;
c. Contraindications; and
d. Medications as disclosed by the client.
(b) Progress notes signed by a Massage Therapist rendering the Massage therapy, which shall include:
1. Subjective information, including the area of complaint as stated by the client and the date of onset;
2. Objective information, including any observations and objective testing, if applicable;
3. Ongoing assessments, if applicable;
4. Actions taken by the Massage Therapist;
5. Client response to Massage therapy treatment.
(c) A plan of treatment, if applicable, consisting of:
1. Goals or desired outcome of the treatment;
2. Modalities to be rendered;
3. Frequency and duration of treatment;
4. Referral to other professionals, if indicated; and
5. Client self-help education and instruction.

269 CMR 6.00: Facility Licensure
6.06: Record Retention
(1) Required records shall be maintained in a manner that protects them from foreseeable damage or destruction.

(a) A Massage Therapy Establishment shall maintain required records on the premises for each active patient.

(b) For a patient who is under two years of age when he or she receives Massage Therapy, records shall be maintained at least until the patient reaches nine years of age.

(c) For patients who receive Massage Therapy on or after the patient reaches two years of age, records shall be maintained for a minimum of seven years from the date of the last patient encounter.

(d) Records stored electronically shall have an established system of weekly back-up. Copies of the back-up records shall be maintained safely and securely.

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Permalink Reply by Kelly Grounds on February 28, 2010 at 11:41pm

So far, Tennessee has nothing on the books. I brought this example up to one of the members of the board. Hopefully this can be resolved soon and something will be 'in writing'.

Henry Hardnock said:

depending on states requirements Texas requires client info form on each new client and update notes each time they come in after.
we have to keep those on file for 2 years and if we get audited and cant produce those forms we could get fined.
so check with your massage laws and give that to the spa.
i would suspect they are afraid you are going to take their potential client away.
i was approached by the rehab physical therapy clinic i work at for the same thing they wanted me to sign a waver stating i would turn in my forms if i left the clinic. i told them no and showed them the rules nothing else was said and im still working there.

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Permalink Reply by Susan G. Salvo on March 1, 2010 at 1:32pm

My instructor used this analogy:

If you had a medical treatment done in a local clinic and, a year later, need copies of your documents, you would contact the clinic where the treatment was preformed rather than the person who provided the treatment.

I'm not expressing an opinion with the analogy, but it was helpful when thinking about it from a client’s perspective.

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