Massage Therapy Charts

It is your job as a massage therapist to document each massage before and after it occurs.

First, the client may have contraindications that would prevent massage or there may be certain problems the client is experiencing in parts of the body that would have to be avoided during a massage. This protects both you and the client from spread of infections, pain, bruising, and possible lawsuits.

Then you need to go over the form and, sitting face to face with the client, conduct a consultation, asking questions and jotting down answers in the charting portion of the client's file. Find out the reason for the visit, whether relaxation or a problem. Go over any medical conditions, medications, and possible contraindications with the client.

Put down anything in the massage therapy charts that you feel may be important. You may want to include any personal preferences the client has such as room temperature, music, aromatherapy... so you will remember before the next visit. The client will be impressed that you remembered. It is your job to please the client.

If you feel that the client needs treatment that is outside the scope of your practice, you will need to refer him/her to the proper health care provider.

If there are any absolute contraindications, you will have to let the client know that the massage cannot be done. If there are local contraindications present, be sure and avoid those areas during the massage. Discuss this during the consultation so the client will know that you are protecting him/her during the massage. Always document this in your massage therapy charts.

After the massage, you need to make notes documenting the massage in the charting. Include what you observed and felt, any problem areas, the strokes you used on these areas, and any reaction from the client. Also include any favorite strokes that the client enjoyed so you can perform those same strokes on the next visit. Always initial and date your charting.

When the client comes back for the next massage, your record keeping in your clients' charts will prove invaluable. You will need to go over the charting notes from the previous visit ahead of time. Ask the client how the prior problems (if any) are coming along. Find out if there are any new issues or concerns and chart those.

Always ask if the client would like to schedule another visit, especially if the client is having pain. Remember to show your client that you care and that you are there to help.

Good record keeping is necessary but does not have to be difficult. It can make or break your business. You must have documentation if you have to go to court or if the client's physician needs to see the charting to better treat the client.

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