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Do SOAP notes belong to the I.C. or the spa owner?
I recently left my practice at a dayspa where I was an independent contractor. I was responsible for my own intake forms, the secure file and all my own supplies. When I left, the owner called me and demanded that I return the SOAP charts because they were her property. I disagreed and after some discussion, I deducted she was afraid I would use the names and addresses for my own mailing list. I assured her I had no such desire and if she wanted, she could make copies for me and block out the names. In the end, she trusted me to make copies to return to her. She has all the names and addresses on her computer. I don't know why she needs the SOAP notes unless it is to give to her new IC therapists. In the future, I am going to spell this out on my rental contracts/I.C. contracts. Thoughts?
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Replies to This Discussion
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Permalink Reply by ellen on
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I worked at an agency where we hired independent contractors in another profession, (mental health) and we did require our contracted employees to give us their notes. If we didn't keep them, we would lose the contract we had with the state, so I can see the position that the agency took and it made sense in that situation.
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Permalink Reply by Kelly Grounds on
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Yes, in that case I can see that as well. However, what if a client came back AFTER a therapist had left but before the statute of limitions to sue was up, claiming injury. It would be the Independent contractors, not the agency, who would be legally responsible and would have no paperwork or notes to back his/her side of the story. This is why I insisted on keeping copies of my SOAP notes.
ellen said:I worked at an agency where we hired independent contractors in another profession, (mental health) and we did require our contracted employees to give us their notes. If we didn't keep them, we would lose the contract we had with the state, so I can see the position that the agency took and it made sense in that situation.
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Permalink Reply by Travis Alligood on
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They are yours and, I would make them get a court order to get even a copy from me. NO QUESTION ! See ya downtown Peace !
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Permalink Reply by Jeanne Riley on
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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 Laura Allen on
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Travis, I know that you are in North Carolina, so I am going to tell you that you are misinformed. Client files are the property of the CLIENT. They do not belong to the therapist. And it is generally accepted, although not a law, that the establishment gets to keep them. If you take files with you when you leave somewhere, THEY may well take YOU to court. Our board is currently in the planning stage of the process of getting ready to license establishments as well as therapists, and I expect this will all be much clearer when that happens, but in the meantime, don't go taking client files when you leave somewhere. You are asking for a lawsuit, and the law is not on your side. Our board is having a planning meeting on that issue later this week.
All the info below about MA does not apply here---you are expected to keep notes on every session whether it's for relaxation or medical purposes.
Travis Alligood said:They are yours and, I would make them get a court order to get even a copy from me. NO QUESTION ! See ya downtown Peace !
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I am in Tennessee and as of right now, there is nothing on the books regarding soap notes. I am taking my question to the TN massage board when they reopen next Monday with their full staff. I'll keep you posted. I am glad to see MA has something down that I can reference.
Laura, I know the client files actually belong to the clients but who is in charge of protecting them? Are you suggesting that when an IC leaves a place, they send the files to the clients?(probably not a bad idea...) But my doctors don't do this! My GP and my Pediatrician both moved states at the end of 09 and without warning sent our files to new doctors. I was told if I wanted a different doctor, I would have to request my files in writing and then drive across town to pick them up after I had gotten approval. Now I will probably do this, but honestly how many people will just see a new doctor and start their files from scratch.
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No--but the smart thing to do if you are leaving someone's place of employment, and the client is going to follow you, is to ask the client to request their files.
I have many times seen notices printed in the newspaper when a doctor is retiring or moving away stating that files had to be picked up by such-and-such date, or thereafter would be at Dr. So-and-So's office. I would think they are obligated to notify people.
Kelly Grounds said:I am in Tennessee and as of right now, there is nothing on the books regarding soap notes. I am taking my question to the TN massage board when they reopen next Monday with their full staff. I'll keep you posted. I am glad to see MA has something down that I can reference.
Laura, I know the client files actually belong to the clients but who is in charge of protecting them? Are you suggesting that when an IC leaves a place, they send the files to the clients?(probably not a bad idea...) But my doctors don't do this! My GP and my Pediatrician both moved states at the end of 09 and without warning sent our files to new doctors. I was told if I wanted a different doctor, I would have to request my files in writing and then drive across town to pick them up after I had gotten approval. Now I will probably do this, but honestly how many people will just see a new doctor and start their files from scratch.
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Hmmm I don't get newspapers anymore, so I don't know which newspaper if any my docs posted to. Nor did the dayspa allow me to send out emails to clients and tell them I was leaving. I am rather irked looking back at this because many of the clients were cultivated by me through direct mailings I did myself and networking opportunities. Since I am now teaching full time, and not doing massage at the moment, this isn't such a big deal. However, it is definitely a 'lesson learned' that I will be teaching to my students in business class. Just when you think you've covered everything in a letter of agreement or contract, look again!
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Kelly and the rest---here's what I personally did when I left my employer and started my own practice: placed several big ads that stated "Laura Allen, formerly of The Whole You, is now in business at THERA-SSAGE at 431 S. Main St.,Ste. 2 in Rutherfordton, and looks forward to welcoming former and new clients." There is no law against that, and they can't do a thing about it. It got the word out, and I didn't take any files, just started my own new ones as the clients flocked in.
I would say also that the law is different in different places, there is no clear law in many places, and it would have a lot to do with the way things are handled at the outset. Travis, for instance, brought up working at the Y, which is not exactly a spa or traditional massage establishment. If you are outright renting a room from someone, and they are not doing any advertising or referring to you, and all the equipment is yours, you are supplying all your own laundry, business cards, etc and they are not doing anything for you at all, then it may work for you to keep your client files in your own room, not out in the general files at the Y etc, you would have a stronger leg to stand on as far as taking them with you when you go.
If the establishment is making appointments for you, advertising your services, providing you with any supplies, equipment, referring their clients to you, etc, it would be much harder to win a lawsuit entitling you to take the files. Another term for IC is "contract employee"--implying that you are a company representative, even though technically you are self-employed and paying your own taxes.
Another consideration is what type the establishment is. Mine is primarily a medically-focused clinic, we file a lot of insurance, and we adhere to the HIPAA laws. Our files are to be kept under lock and key, not strolling out the door with a therapist who leaves. But of course if a client comes in and requests them, I will hand them over to them.
Kelly Grounds said:Hmmm I don't get newspapers anymore, so I don't know which newspaper if any my docs posted to. Nor did the dayspa allow me to send out emails to clients and tell them I was leaving. I am rather irked looking back at this because many of the clients were cultivated by me through direct mailings I did myself and networking opportunities. Since I am now teaching full time, and not doing massage at the moment, this isn't such a big deal. However, it is definitely a 'lesson learned' that I will be teaching to my students in business class. Just when you think you've covered everything in a letter of agreement or contract, look again!
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Laura,
Thank-you for your response, on this subject. You can bet that I will be paying attention to this subject. However when I went to school to become a Massage Therapist I did it with the intention of working for myself and no body else, however being in the first year of my business dont think it hasn`t cross my mind to work for someone else, but my gut-check kicked in kept me from it. So with that said I will be watching out for further dicussion, Thanks again for your response. Peace Travis
Laura Allen said:Kelly and the rest---here's what I personally did when I left my employer and started my own practice: placed several big ads that stated "Laura Allen, formerly of The Whole You, is now in business at THERA-SSAGE at 431 S. Main St.,Ste. 2 in Rutherfordton, and looks forward to welcoming former and new clients." There is no law against that, and they can't do a thing about it. It got the word out, and I didn't take any files, just started my own new ones as the clients flocked in.
I would say also that the law is different in different places, there is no clear law in many places, and it would have a lot to do with the way things are handled at the outset. Travis, for instance, brought up working at the Y, which is not exactly a spa or traditional massage establishment. If you are outright renting a room from someone, and they are not doing any advertising or referring to you, and all the equipment is yours, you are supplying all your own laundry, business cards, etc and they are not doing anything for you at all, then it may work for you to keep your client files in your own room, not out in the general files at the Y etc, you would have a stronger leg to stand on as far as taking them with you when you go.
If the establishment is making appointments for you, advertising your services, providing you with any supplies, equipment, referring their clients to you, etc, it would be much harder to win a lawsuit entitling you to take the files. Another term for IC is "contract employee"--implying that you are a company representative, even though technically you are self-employed and paying your own taxes.
Another consideration is what type the establishment is. Mine is primarily a medically-focused clinic, we file a lot of insurance, and we adhere to the HIPAA laws. Our files are to be kept under lock and key, not strolling out the door with a therapist who leaves. But of course if a client comes in and requests them, I will hand them over to them.
Kelly Grounds said:Hmmm I don't get newspapers anymore, so I don't know which newspaper if any my docs posted to. Nor did the dayspa allow me to send out emails to clients and tell them I was leaving. I am rather irked looking back at this because many of the clients were cultivated by me through direct mailings I did myself and networking opportunities. Since I am now teaching full time, and not doing massage at the moment, this isn't such a big deal. However, it is definitely a 'lesson learned' that I will be teaching to my students in business class. Just when you think you've covered everything in a letter of agreement or contract, look again!
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Permalink Reply by rudy m smith on
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I would contact a good attorney - HIPA comes to mind. Since your a private contractor you should be responsible for safeguarding their private information. The problem here is with a business owner that wants their cake and to eat it too. Meaning - they want you to pay all your own expenses and they don't want the hassle of employees. I would bet if the client got hurt some how they would all of a sudden say (you are on your own). The IRS defines these relationships with some simple rules. Again have a CPA look at how you are (used) or quazi employed and have an attorney counsel you on privacy act issues. Personaly if I work on someone, any notes about them from my time with them is my property and responsibility.
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This is facinating, definatley worthy of good legal counsel -- I see many business's come and go and owners move away which would leave the therapist with no records. Hmm. real legal beagle issues here.
Laura Allen said:Travis, I know that you are in North Carolina, so I am going to tell you that you are misinformed. Client files are the property of the CLIENT. They do not belong to the therapist. And it is generally accepted, although not a law, that the establishment gets to keep them. If you take files with you when you leave somewhere, THEY may well take YOU to court. Our board is currently in the planning stage of the process of getting ready to license establishments as well as therapists, and I expect this will all be much clearer when that happens, but in the meantime, don't go taking client files when you leave somewhere. You are asking for a lawsuit, and the law is not on your side. Our board is having a planning meeting on that issue later this week.
All the info below about MA does not apply here---you are expected to keep notes on every session whether it's for relaxation or medical purposes.
Travis Alligood said:They are yours and, I would make them get a court order to get even a copy from me. NO QUESTION ! See ya downtown Peace !
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