Sec. 10.65.06.01. General Requirements

A. The license or registration holder 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.