1. (1) The Massage Therapist and client shall agree upon the purpose of the Massage session;
2. (2) No documentation is required if the Massage session is given during sports or other kind of public events, or given in a public setting as in chair Massage, unless the client is younger than 18 years old. If the client is younger than 18 years old, the therapist must obtain written permission of either a parent or a legal guardian for the minor client’s receipt of massage therapy;
3. (3) A Massage Therapist who provides a massage for the purpose of general relaxation shall document, at a minimum, their own name, the name of the client, the date and time of the session, any contraindications, and the client’s Informed Consent for treatment.

4. (4) If a written plan of treatment is requested or required, Massage Therapist shall document the following information in the client’s file within 24 hours of service:

   1. (a) The initial evaluation, which shall include:

      1. 1. The client’s name and date of birth;
      2. 2. Date of the session;

      3. 3. Pertinent medical history, including, but not limited to:

         1. a. Client sensitivities and allergies;
         2. b. Medical diagnoses, if available, and the source of the diagnosis;
         3. c. Contraindications;
         4. d. Medications as disclosed by the client, and
         5. e. Informed Consent.

   2. (b) Progress notes signed by a Massage Therapist rendering the massage therapy, which shall include:

      1. 1. Subjective information, including the area of complaint as stated by the client and the date of onset;
      2. 2. Objective information, including any observations, if applicable;
      3. 3. Actions taken by the Massage Therapist;
      4. 4. Client response to massage therapy treatment.

   3. (c) Therapist recommendations, if applicable, consisting of:

      1. 1. Goals or desired outcome of the treatment;
      2. 2. Modalities to be rendered;
      3. 3. Frequency and duration of treatment;
      4. 4. Referral to other professionals, if indicated; and
      5. 5. Client self-help education and instruction.

REGULATORY AUTHORITY

269 CMR 5.00: M.G.L. c. 13, § 99; c. 112, § 234.