Taking Clinical Notes/Records is an important and necessary aspect of being a professional therapist. Taking adequate and appropriate records ensures therapists are able to monitor the health of clients as well as meeting your Private Health Fund and Association requirements. Maintaining records is also a legislative requirement under the National Code of Conduct for Health Care Workers.

The Code of Conduct requires therapists to maintain accurate, legible and current clinical records for each client and every consultation. Records in either hardcopy, digital, or both, must be held securely and not be subject to unauthorised access. Therapists need to take the necessary steps to assist clients’ access to information contained in their health records if requested and ensure that records are transferred in a timely manner when requested to do so by the client or their legal representative. 

Components of Clinical Notes need to include the following:

  • Informed Consent
  • Treatment Plan 
  • Assessment Plan
  • Contraindication (natural and prescribed).

Massage & Myotherapy Australia has produced a series of Informed Consent and Client History Forms available to members only. The Association recommends that members use these as a source to create their own Informed Consent and Client History Form. 

If your massage therapist, remedial massage therapist or myotherapist does not take clinical records after treatment, you can notify Massage & Myotherapy by email at info@massagemyotherapy.com.au or by making an official complaint. 


Informed Consent

Therapeutic Client History Form

Remedial Client History Form

 Myotherapy Client History Form