Record Keeping

Why This Matters for MTs

Clinical records are legal documents. In a complaint investigation, insurance dispute, or malpractice claim, the record is the primary evidence of what happened during treatment.
The standard in healthcare: "If it was not documented, it did not happen."
PHIPA designates RMTs as health information custodians (HICs), creating specific legal obligations for how personal health information is collected, used, disclosed, and stored.

Every client encounter requires documentation. The minimum clinical record includes:

Client identification: Full name, date of birth, contact information, emergency contact.
Health history: Comprehensive intake form covering medical history, current medications, allergies, surgeries, current complaints, and relevant psychosocial factors. Use the LORDFICARAHM mnemonic for complaint-specific history.
Informed consent: Documentation that consent was obtained, including what was explained (nature of treatment, expected benefits, material risks, alternatives, right to withdraw). Separate written consent for sensitive areas (inner thigh, chest/breast, gluteal, inguinal).
Assessment findings: Observations, palpation findings, ROM results, special test results, postural assessment, pain ratings.
Treatment plan: Goals (short-term and long-term), proposed techniques, frequency, expected outcomes.
Treatment record (SOAP notes): Documentation of each session.
Re-assessment findings: Outcome measures tracked over time.
Discharge or discontinuation notes: Reason for ending care, recommendations, referrals made.

The standard documentation format for MT treatment records:

S (Subjective): Client-reported symptoms, concerns, and response to previous treatment. Use the client's own words where possible. Include pain scale ratings, functional limitations, and changes since the last visit.
O (Objective): Therapist's measurable findings. Assessment results (ROM, special tests, palpation findings), treatment delivered (techniques used, areas treated, duration, pressure, client response), and any adverse events.
A (Assessment): Clinical reasoning summary. What the findings mean, progress toward goals, working clinical impression, and any changes to the clinical picture.
P (Plan): Next steps. Modifications to the treatment plan, home care recommendations, frequency of future visits, referrals to other HCPs, and planned re-assessment points.

Write legibly (or type) in permanent ink (no pencil for paper records).
Date and sign every entry.
Use accepted medical abbreviations only.
Never use whiteout or erase entries. Draw a single line through errors, initial and date the correction.
Document in real time or as soon as possible after the session — never backdate.
Record objective findings using measurable terms (e.g., "cervical right rotation 60 degrees" rather than "limited ROM").

Standard retention period: 10 years from the date of the last entry in the record.
Minor exception: For clients who were minors (under 18) at the time of treatment, retain records for 10 years after the client turns 18 (i.e., until the client is 28).
After retention period expires: Records must be destroyed securely (shredding for paper, permanent deletion for digital).
Practice closure or sale: The CMTO requires a plan for secure transfer or storage of records. Clients must be notified and given the opportunity to request their records.

Paper records: Locked filing cabinets in a secure area. Only authorized personnel may access.
Digital records: Password-protected systems with encryption. Regular backups. See Electronic Information Management.
PHIPA compliance: Personal health information must be protected against theft, loss, and unauthorized access, use, disclosure, copying, modification, or disposal.
Access requests: Clients have the right to access their own records under PHIPA. You must respond within 30 days of a request. You may charge a reasonable fee for copies.
Breach response: If a privacy breach occurs (unauthorized access, loss, theft of records), you must notify the client and report to the Information and Privacy Commissioner of Ontario (IPC) if the breach poses a risk of significant harm.

Complete the health history form at the first visit and update it at least annually or whenever the client reports a significant health change.
Write SOAP notes for every treatment session — even brief visits.
Obtain and document informed consent before the first treatment and re-confirm consent when changing the treatment plan, adding new techniques, or treating sensitive areas.
Use standardized forms that prompt you to capture all required elements (this reduces the risk of omissions).
Set up a record retention calendar to track when records can be securely destroyed.
If you work in a multi-therapist clinic, clarify record ownership and access policies with the clinic owner.

PC 1.2d: Maintain appropriate records.
PI 1.2d.1: Create and maintain accurate, complete, and timely client records.
PI 1.2d.2: Maintain confidentiality, security, and appropriate access to client records.
PI 1.2d.3: Comply with applicable legislation regarding record keeping.

MCQ questions commonly test retention periods (10 years / minor exception), SOAP components, and PHIPA obligations.
OSCE stations may require documenting findings, writing a SOAP note, or explaining a client's right to access their records.
Jurisprudence exam covers PHIPA obligations, breach reporting, and retention requirements.

Every client encounter requires documentation — health history, informed consent, assessment, SOAP notes, and treatment plan.
SOAP format (Subjective, Objective, Assessment, Plan) is the standard for MT treatment records.
Records must be retained for 10 years from the last entry, or until a minor client turns 28, whichever is later.
PHIPA designates RMTs as health information custodians with legal obligations for privacy, security, access, and breach reporting.
"If it was not documented, it did not happen" — documentation is your primary defense in any investigation or dispute.