Section 338.727. Client records.

(1) A licensee shall maintain a legible client record for each client, which accurately reflects the licensee’s assessment and treatment of the client. Entries in the client record shall be made in a timely fashion.

(2)    The client record shall contain all of the following information:

(a)    The name of the massage therapist providing treatment.

(b)         The  client’s  full  name,  address,  date  of  birth,   gender,  and  other   information sufficient to identify the client.

(c)      If the client is less than 18 years of age, written permission of either a parent or guardian for the minor client’s receipt of massage therapy.

(d)          Information  identifying  any  pre-existing  conditions  the  client  may   have  or verification that the client has no pre-existing conditions.

(e)     )  Dates of service and date of entry in the client record.

(f)    )  A client record entry for an initial client visit that includes all of the following:

(i)     History, including description of presenting condition.

(ii)     Therapeutic assessment, if applicable.

(iii)     Treatment or care provided, if applicable. Outcome, if available.

(g)     A client record entry for subsequent assessments, treatments, or care provided that includes all of the following:

(i)     Change in condition.

(ii)     Therapeutic assessment, if applicable.

(iii)     Treatment or care provided, if applicable. Outcome, if available.

(h)     If applicable, a referral to another health care provider.

(3)     For massage therapy treatment provided at a special event, a licensee shall maintain a client record that meets the requirements of subrules (1) and (2) of this rule or an abbreviated client record, as specified in subrule (4) of this rule. For purposes of this subrule, “special event” means any of the following:

(a)     )  A charitable, community, or sporting events.

(b)     One-time events.

(c)     )  Massages performed at any location that are 20 minutes or less in duration.

(4)     An abbreviated client record allowed under subrule (3) of this rule shall consist of, at a minimum, a completed intake form that contains all of the following information:

(a)     The client’s full name, date of birth, and an address or telephone number where the client can be contacted.

(b)     The information listed in subrule (2)(a), (c), (d) and (e) of this rule.

(5)     Under section 16213 of the code, a licensee shall retain a client record for at least 7 years from the date of the last massage therapy treatment for which a client record entry is required. A licensee shall retain the client record for a minor client until 1 year after the minor client reaches 18 years of age, even if this results in the record being retained for more than 7 years.

History: 2012 AACS.