1. A. The licensee or registrant shall maintain accurate, legible, and organized client records for every client, regardless of the procedure or modality employed.

2. B. Sufficient information to be obtained and recorded shall include, at a minimum:

   1. (1) Name, address, and other appropriate contact information;
   2. (2) Summarized client history;
   3. (3) Summarized reason for appointment or referral, including referral documentation, including forwarded reports and correspondence, if applicable;
   4. (4) Billing and insurance documentation, if applicable; and

   5. (5) Massage session summary in standard SOAP format, or its equivalent, which includes, at a minimum:

      1. (a) Initial client assessment, including contraindications noted;
      2. (b) Summarized therapy plan; and
      3. (c) Progress notes, reflecting: summary of techniques used and response to techniques.

Authority: Health Occupations Article, §6-206, Annotated Code of Maryland

Effective date:

Chapter recodified from COMAR 10.43.21 to COMAR 10.65.06 under new Subtitle, Board of Massage Therapy Examiners, Record Keeping, effective January 2, 2017 (43:26 Md. R. 1446)

Regulation .01A amended effective August 5, 2024 (51:15 Md. R. 710)

Regulation .02 amended effective August 5, 2024 (51:15 Md. R. 710)