Plain Text Law

Chapter 06. Record Keeping

Full chapter: Markdown · XML

Regulation .01 General Requirements.Copy Citation

HTML · MD · XML
A.
The licensee or registrant shall maintain accurate, legible, and organized client records for every client, regardless of the procedure or modality employed.
B.
Sufficient information to be obtained and recorded shall include, at a minimum:
(1)
Name, address, and other appropriate contact information;
(2)
Summarized client history;
(3)
Summarized reason for appointment or referral, including referral documentation, including forwarded reports and correspondence, if applicable;
(4)
Billing and insurance documentation, if applicable; and
(5)
Massage session summary in standard SOAP format, or its equivalent, which includes, at a minimum:
(a)
Initial client assessment, including contraindications noted;
(b)
Summarized therapy plan; and
(c)
Progress notes, reflecting: summary of techniques used and response to techniques.

Regulation .02 Maintenance and Release of Records.Copy Citation

HTML · MD · XML
A.
The licensee or registrant shall keep all client files secure and confidential in accordance with the provisions of Health-General Article, Title 4, Subtitle 3, Annotated Code of Maryland.
B.
Client files are the property of the:
(1)
Licensee or registrant when working as a sole proprietor or independent contractor; or
(2)
Practice owner if the practitioner is an employee.
C.
Client files shall be released in a timely manner when authorized by the client in writing or compelled by law or regulation.
D.
The licensee or registrant may assess fees for duplicating client records for the patient or for another health care provider in accordance with Health-General Article, §4-403, Annotated Code of Maryland.
Chapter annotations
Authority: Health Occupations Article, §6-206, Annotated Code of Maryland
History: Effective date:
History: Chapter recodified from COMAR 10.43.21 to COMAR 10.65.06 under new Subtitle, Board of Massage Therapy Examiners, Record Keeping, effective January 2, 2017 (43:26 Md. R. 1446)
History: Regulation .01A amended effective August 5, 2024 (51:15 Md. R. 710)
History: Regulation .02 amended effective August 5, 2024 (51:15 Md. R. 710)