The Massage Therapy Career Focus Workbook

Documentation — Options:

OPTION 1) Basic:

Basic documentation can range from nothing more than issuing receipts to your clients, to recording a few details about the treatments you deliver. Essentially, the basic detail option is for you if you prefer doing massage rather than recording the particulars of who and how you massaged. In other words, you hate paperwork.

OPTION 2) Comprehensive:

Comprehensive documentation involves maintaining and providing extensive documents which thoroughly record a client's time with you. From intake and treatment documentation, through to follow-up analysis and recommendations, your recording procedures will be exhaustive.

Documentation — Understanding Your Options:

As a focus principle, documentation is a compatibility issue. You must determine if your chosen core focus and the documentation needs of potential end-users are compatible with your feelings about paperwork. This interplay between personal needs, core focus, and the needs of end-users should be resolved as early in your career as possible.

First, there is the issue of whether your preferred documentation focus is compatible with your preferred core focus choice. Usually, the required level of documentation detail tends to increase as one moves from an experiential psychosocial core focus up to the corrective biomechanical core focus.

However, this is not a law written in stone. You can provide biomechanical corrective outcomes and keep only basic, if any, documentation. But you can only do this when no one else needs to know what transpired during the treatments. Which leads us to the second issue—end-users.

End-users of documentation can be one or all of the following: you; your client; other therapists; other health professionals such as chiropractors, physical therapists and physicians; lawyers; and finally, third party payers such as health insurance providers.

If the end-user of the treatment documentation is only yourself, then the level of thoroughness and technical depth is up to you. If the end-users include your clients, then it must be at a detail level that makes sense to them. If the end-users include third-party payers and other health professionals, then you will definitely need to provide comprehensive treatment documentation. Therefore, if you have an aversion to keeping comprehensive treatment records, be aware of it now. Your decision will impact where you work and the types of clients you attract.

But remember, as we said earlier, you can provide biomechanical corrective outcomes and keep zero documentation; just don't expect many referrals from other health professionals or to work in a clinic which does insurance claims. You could also provide experiential psychosocial outcomes and keep mountains of treatment detail; just don't expect your clients to enjoy being put through range of motion exercises or listening to you review the details of their last treatment.