<?xml version='1.0' encoding='utf-8'?>
<chapter num="06" heading="Record Keeping" title_num="10" subtitle_num="65">
  <regulation prefix="Regulation" num=".01" 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>
  <regulation prefix="Regulation" num=".02" heading="Maintenance and Release of Records.">
    <paragraph num="A.">
      <text>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.</text>
    </paragraph>
    <paragraph num="B.">
      <text>Client files are the property of the:</text>
      <paragraph num="(1)">
        <text>Licensee or registrant when working as a sole proprietor or independent contractor; or</text>
      </paragraph>
      <paragraph num="(2)">
        <text>Practice owner if the practitioner is an employee.</text>
      </paragraph>
    </paragraph>
    <paragraph num="C.">
      <text>Client files shall be released in a timely manner when authorized by the client in writing or compelled by law or regulation.</text>
    </paragraph>
    <paragraph num="D.">
      <text>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.</text>
    </paragraph>
  </regulation>
  <annotations>
    <annotation type="Authority">Health Occupations Article, §6-206, Annotated Code of Maryland</annotation>
    <annotation type="History" subtype="Administrative History">Effective date:</annotation>
    <annotation type="History" subtype="Administrative 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)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .01A amended effective August 5, 2024 (51:15 Md. R. 710)</annotation>
    <annotation type="History" subtype="Administrative History">Regulation .02 amended effective August 5, 2024 (51:15 Md. R. 710)</annotation>
  </annotations>
</chapter>