Chapter 23:

Progress Notes


“maintain adequate progress notes for each client session, if applicable.”

--NCBTMB Standards of Practice IV (c)


Record keeping is particularly applicable when working for or with another professional. The other person will want to see what progress is being made and may need the documentation for insurance or tracking the status of the client. Massage/ bodywork may be part of a larger plan of care embodying other disciplines and other providers. Proper record keeping prevents any confusion or embarrassing moments where competency might be questioned.


The licensing jurisdiction usually requires some form of records be kept. The information most commonly needed is whether the client has any condition which may be contraindicative in massage. The therapist may wish to limit information collected to that and what is required by ethics and licensing jurisdictions; the exception being where more information is required because another discipline, such as chiropractic, is also involved.


The nationally certified therapist is required to obtain consent for treatment and retain records.


A progress report may not be applicable when the massage is recreational and not meant for therapy.


To next chapter

Chapters