SECTION 175:20-9-2. Client Records

(a)   A licensee shall maintain the confidentiality of client information at all times and not disclose the client's identity or other information unless release of information is:

(1)   consented to in writing by the client;

(2)   required for the purpose of immediate treatment of the client by a third party; or

(3)   otherwise required by law.

(b)   A licensee shall maintain client files and business records for at least three (3) years from the date of service and in a manner that secures client confidentiality.

(c)   A licensee shall dispose of client records in a secure manner that prevents disclosure of personal information.

(d)   A licensee shall obtain informed written consent from all clients. If the client is a minor, the licensee shall obtain written consent from the client's parent or legal guardian. The client intake form shall include the client's name, gender, date of birth, date of session, pertinent medical history, client sensitivities, allergies and medication.

(e)   If a written plan of treatment is required, the client file shall include the intake form, progress notes signed by the licensee, complaints, ongoing assessments, client's response to treatment, referrals to other professionals if indicated, and goals or desired outcome of treatment medications as disclosed by the client.

(f)   In performing a sports event massage, a public demonstration or seated massage, a licensee may obtain a written consent without an intake form but with notification of pre-existing conditions that could affect the massage.

[Source: Added at 34 Ok Reg 437, eff 1-23-17 (emergency); Added at 34 Ok Reg 1050, eff 9-11-17; Amended at 35 Ok Reg 1086, eff 9-14-18]