Standards of Practice, Recordkeeping, and Informed Consent
Informed consent
Before treatment, explain the techniques, expected benefits, risks, alternatives, draping and boundary rules, and the client's right to refuse or stop at any time. Obtain and document consent. For a minor, obtain parent or guardian consent as required. Consent is ongoing: if the client withdraws it, stop. Intimate areas are never within routine massage consent; separate, specific consent and a therapeutic justification are required, and many settings prohibit them entirely.
Recordkeeping
Keep a client record with intake and health history, medications, allergies, contraindications, assessment, treatment plan, areas treated, techniques, client response, consent, referrals, and dates. Retain records for at least five years after the last service, or longer if Board regulation or other law requires. Store records securely and release them only with written authorization or as required by law. Do not alter a record after a complaint; make a late entry clearly dated and signed.
Worked example
A client discloses pregnancy at 28 weeks. The therapist documents the disclosure, avoids deep abdominal work and contraindicated positions, uses side-lying positioning with pillows, explains the change, and refers the client to her obstetric provider for any pain or bleeding. The record shows the reasoning, not just 'prenatal massage.' That documentation protects the client and demonstrates standard of care.
Traps that cost marks
- Relying on a signed form without a conversation.
- Treating silence as consent.
- Recording gossip or irrelevant personal details.
- Promising confidentiality when a mandatory report is required.
- Failing to document contraindications and referrals.