Code of Massachusetts Regulations
269 CMR - BOARD OF REGISTRATION OF MASSAGE THERAPY
Title 269 CMR 5.00 - Code Of Professional Ethics & Standards Of Ethical Practice
Section 5.03 - Standards for Documentation
Universal Citation: 269 MA Code of Regs 269.5
Current through Register 1531, September 27, 2024
(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 younger than 18 years old. If the client is younger than 18 years old, 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 contemporaneously created 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.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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