<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".01" citation="COMAR 10.65.06.01" title_num="10" subtitle_num="65" chapter_num="06" heading="General Requirements.">
  <paragraph num="A.">
    <text>The licensee or registrant shall maintain accurate, legible, and organized client records for every client, regardless of the procedure or modality employed.</text>
  </paragraph>
  <paragraph num="B.">
    <text>Sufficient information to be obtained and recorded shall include, at a minimum:</text>
    <paragraph num="(1)">
      <text>Name, address, and other appropriate contact information;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Summarized client history;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Summarized reason for appointment or referral, including referral documentation, including forwarded reports and correspondence, if applicable;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Billing and insurance documentation, if applicable; and</text>
    </paragraph>
    <paragraph num="(5)">
      <text>Massage session summary in standard SOAP format, or its equivalent, which includes, at a minimum:</text>
      <paragraph num="(a)">
        <text>Initial client assessment, including contraindications noted;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Summarized therapy plan; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Progress notes, reflecting: summary of techniques used and response to techniques.</text>
      </paragraph>
    </paragraph>
  </paragraph>
</regulation>