Record keeping is a professional duty in any holistic health care practice. We require members use the same record keeping standards as the massage therapy regulatory colleges in Canada.
Health History and Intake Forms
Health history and intake forms give the information necessary to decide the best treatment for the client. They must include the following:
- general client information
- complete health history
- details of client assessment
- full treatment plan
- signed and dated informed consent form
Treatment Documentation
It is important for practitioners to fully document a client's treatment, including the following:
- detailed treatment/clinical/SOAP notes
- appointment attendance
- financial information and billing details
- receipts that follow the standards of the Canadian Life and Health Insurance Association (CLHIA)
