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Fees and Billing

No, the College does not set fees for the members to charge. However, fees must meet expectations for honesty and accuracy (generally accepted rates for the profession) and must not be excessive.

A fee is excessive when it takes advantage of a patient or is so high that the profession would conclude that the member is exploiting patients. Prior to receiving treatment, patients must be advised of the fee to be charged so that they can make an informed decision before proceeding.

No, the Advertising Guideline sets out that members must bill per service, and are not allowed to accept payment for a bundle of treatments in advance.

Yes, if the patient is billed for each of the ten treatments separately (e.g., after each treatment is provided).

No, if the patient is expected to pay for the ten treatments upfront.

Members may, at their discretion, provide discounts as long as they meet the standards of the College, are clearly advertised, and are not discriminatory or put certain patients at a disadvantage.

When deciding to offer discounts to a specific group of patients, practitioners must adhere to the legislation governing the practice of the profession, including relevant provincial regulations, such as the Human Rights Code.

The Ontario Human Rights Commission (OHRC) permits programs and benefits aimed at specific age groups in certain circumstances. For example, if the purpose of the program is to relieve hardship or economic disadvantage or to assist disadvantaged persons or groups in achieving equal opportunity.

As such, seniors’ or students’ discounts may be permitted, while discounts based on sex or citizenship, for example, would be considered discriminatory.

Insurance companies set their own policies, and coverage can vary from employer to employer. The College does not have the jurisdiction to influence private insurance companies’ policy coverage options. Some members have reached out to their respective professional associations/MPPs to address these issues.

Testimonials

Yes, Google reviews may be considered as testimonials. Even if the information is provided anonymously, it can still qualify as a testimonial. These are often subjective statements from a patient or other individual expressing an opinion about the nature or quality of the member’s services. As such, testimonials may mislead the public.

The College recognizes that members do not have control over third party websites such as RateMD, Yelp or Google. If the member becomes aware that a testimonial is on a site, the member must make all reasonable efforts to have the testimonial removed.

A reasonable step would be to contact these websites and keep a record of your attempts in the event that the College inquires about the advertising. For example, RateMD has an email where concerns can be reported.

Name/Designation

Members are expected to use their titles and designations when acting in a professional capacity, e.g. in advertising, and on business cards and invoices.

The titles and designations that each class of registered members may use are set out in the College’s Registration Regulation. Only qualified practitioners who meet the requirements of the College are authorized to use these titles and designations.

However, practitioners cannot use the College logo in their promotional materials or other business documents. The logo is the property of the College and is only to be used for College matters.

Members must advertise and practice the profession using the name they have registered with the College.

If a member has created a Professional Corporation, they can use a name other than the registered name of the Professional Corporation in its advertising. However, the name of the Professional Corporation must also be listed in the advertising. This ensures that members of the public are fully informed about the Professional Corporation.

You will need to send an email to the Registration department with the name that you would like to have listed as your common name used in practice. Once updated, your common name will also appear on the College’s public register.

No, a member who has obtained a Ph.D. may not use the Doctor title or designation in the course of providing or offering healthcare. Under section 33 of the Regulated Health Professions Act, 1991 (RHPA), no one is allowed to use the title “doctor”, its variation or abbreviation or an equivalent in another language when providing or offering to provide health care in Ontario, unless he/she is a member of:

  • the College of Chiropractors of Ontario;
  • the College of Optometrists of Ontario;
  • the College of Physicians and Surgeons of Ontario;
  • the College of Psychologists of Ontario;
  • the College of Naturopaths of Ontario (with the ND designation following their name); or
  • the Royal College of Dental Surgeons of Ontario.

Note that if the member is not in a clinical setting (i.e. if they are teaching) then it would be permissible to use the “Dr.” title. This is because there is no confusion that the member is offering or providing healthcare.

General

While the College recognizes that some members may receive training in a specialized field and that a large number of their clients may present with similar conditions, members must not advertise that they are specialists in an area.

An example of an acceptable language for advertising experiences would be to state that “Conditions we have treated include: a, b, c…”

No. Members may not provide before and after photos of how one’s services improve a patient’s appearance, as this is inherently misleading and unverifiable.

Similarly, different patients may react differently to the same treatment. Given these circumstances, posting of before and after pictures would be inappropriate as it will provide a false impression and/or expectation from the patient that a certain treatment will yield a certain result.

Many members use social media in their private and professional lives. It is important to recognize that in the context of social media, the line between personal and professional life may not be obvious. Social media, such as Facebook, Twitter or Instagram, are public-facing platforms even when used for personal reasons.

When using social media, members are advised to follow the same rules that would apply to any other form of communication; for example, by maintaining professional boundaries, protecting patient confidentiality and communicating respectfully and professionally.

Invoices/Receipts

According to the Standard for Fees and Billing, Members must provide receipts that contain:

  • The member’s registration information
  • Names of others involved in the care such as staff or students
  • The clinic name, address, telephone number
  • The patient’s full name, address, and telephone number
  • The date and duration of service
  • An accurate description of the services and products provided
  • The type of payment used and amount received
  • Any balance on the account
  • HST registration number, if applicable

However, the purpose of the standard is to ensure the patient has a complete invoice. Therefore, if a patient is not comfortable with providing their personal contact information to the member or the clinic, the section can remain blank. To ensure that your records are complete, you should note in the patient’s records that this information was omitted at the request of the patient.

No, members are not required to maintain electronic records (patient or financial). A paper or handwritten receipt is satisfactory as long as it includes the following information:

  • The member’s registration information
  • Names of others involved in the care such as staff or students
  • The clinic name, address, telephone number
  • The patient’s full name, address, and telephone number
  • The date and duration of service
  • An accurate description of the services and products provided
  • The type of payment used and amount received
  • Any balance on the account
  • HST registration number, if applicable

At the outset, you would have to maintain a patient record if a free consultation was provided. It would therefore be prudent to also provide an invoice or receipt that indicates a free consultation had been provided. This will form part of your records and demonstrate that no fees were owed. It will also provide evidence to the patient that they were not charged for this appointment.

Practitioners must provide an itemized account for their services and products. Failing to itemize an account for products or services is an act of professional misconduct. The rationale behind this requirement is that patients need to know what was purchased and the price for each item or service. If the patient reviews the invoice several months after the appointment, the patient should be able to easily identify what was purchased.

Receipts must accurately reflect the services and products provided. This includes listing any herbal products and their quantity, whenever relevant. It is important that patients and any relevant third parties understand the charges.

You may wish to include a copy of the herbal prescription along with the receipt to provide further details.

Only those that are involved in the direct care and treatment of the patient need to be included on the receipt. For example, if a student inserted or removed needles during an acupuncture treatment, then their name and the supervisor’s name and registration number must be listed on the receipt. The rationale is that the patient should have a record (that they can take home with them) accurately reflecting what occurred at the appointment and the names of all service providers.

Others not directly involved in the treatment do not need to be included on the document.

Record Keeping

The College recommends that members practicing in a group setting have a written agreement that clearly establishes who will act as the agent and health information custodian, and be responsible for maintaining patient records. This includes financial records. This is important as patients need to be able to access and retrieve their records. Setting down the respective obligations of members and employers will ensure that the patients’ right to access their health records is maintained.  

The College also recommends that practitioners have a written confirmation regarding reasonable access to the content of the patient and financial records if needed. The rationale behind this is that there may be situations where the member needs to provide evidence of treatment or respond to a complaint or law suit.

For more information, please see the Record Keeping Guideline.

Yes; however, it is important to remember that you are ultimately accountable for any fee, billing, or account that uses your name and registration number.

In situations where clinic staff help with the administration of financial records, practitioners must ensure the invoice complies with the requirements of this College (i.e., CTCMPAO members cannot rely upon the requirements of another regulatory college, or employer. Members of this College must ensure that any invoice issued for TCM services comply with the requirements of the CTCMPAO). Therefore, practitioners will want to ensure that designated staff members are fully informed as to what is required.

The Standard for Fees and Billing also applies to services provided by telepractice. Practitioners are already required to advise patients of fees prior to providing treatment. Practitioners are also expected to advise their patients (upfront) of any additional fees (if any) associated with telepractice. The fee information must be clear and should not be misleading or hard to understand.

Receipts must provide an accurate representation of the service provided to the patient. If applicable, an invoice should indicate that a service was provided remotely. Practitioners should advise their patients to verify with insurance providers as to whether they cover services provided by telepractice.

No, practitioners who practise in more than one regulated health profession must maintain separate patient and financial records. It must be clear to their patients and third parties what profession they are practising at any given time and what type of service they are providing and in what capacity.

For example, a CTCMPAO member who is also registered with the College of Massage Therapists of Ontario (CMTO) must maintain two completely independent patient and financial records, one for TCM/Acupuncture and one for Massage Therapy.

Members should respond to this request from their patients (however, if there is an administrative fee associated with this request, the patient will need to be advised in advance). Members will want to ensure that any reprint or duplicate receipts are marked as such. Receipts that are reprinted must be clearly marked as duplicate. Any duplication of forms should be noted in the patient’s records for accuracy and comprehensiveness.

Fees

Billing codes are specific to each insurance company. You may need to verify with the various insurance providers your patients are with to confirm this information.

Yes, members may, at their discretion, provide discounts as long as they are clearly advertised and not discriminatory (e.g., the discount cannot be based on patients’ gender, sexual orientation, race, etc.) or put certain patients at a disadvantage. When deciding to offer discounts to a specific group of patients, practitioners must adhere to the College Standards and the relevant provincial regulations, such as the Human Rights Code. For example, the Ontario Human Rights Commission (OHRC) permits programs and benefits aimed at specific age groups in certain circumstances to relieve hardship or economic disadvantage or assist disadvantaged persons or groups in achieving equal opportunity.

No, it is acceptable for practitioners to provide a treatment at a reduced rate based on an individual patient’s circumstances (e.g., financial hardship). The level of reduction would be according to your professional discretion.

The reasons for the fee reduction must be documented in the patient’s file. It is recommended that you have this pricing agreement in writing, as this helps to maintain accurate and verifiable documentation for record keeping.

It would be up to your professional discretion. As a clinic owner, if you wish to provide discounts to your staff members for services or products, it is recommended that you have this policy in writing.

HST is required for cosmetic acupuncture services. The Canada Revenue Agency (CRA) website provides detailed information about acupuncture services and HST.

Practitioners need to ensure that cosmetic treatments are billed accordingly (and that the patient is aware of any additional fees), and recorded accurately in the patient’s health and financial records. It is also recommended that the patient contact their insurance provider to confirm (prior to treatment) that cosmetic acupuncture is covered by their specific benefits plan.

No. An invoice cannot be issued with the name and registration number of a practitioner who did not provide the service.

Members must provide receipts that accurately reflect the service provided and/or product sold. This includes the use of their name and their CTCMPAO registration number. Members will want to ensure that their name and registration number are safely secured and not used inappropriately. Failure to do so is an act of professional misconduct.

No. Patients should not be paying for multiple treatments in advance. Members are expected to bill per service and are not permitted to accept payment in advance of treatment.

A receipt should be provided after each and every treatment. Invoicing patients prior to treatment would be considered falsifying records and submitting charges for treatments that have not yet been provided.

Advertising

Members need to ensure that patients are able to make informed decisions about the cost of their care. The fee schedule should advise of the fees for services and products and any other charges such as late payments, interest and charges for cancellations, etc. Fee schedules can be posted on a website, scheduling app, or clinic pamphlet. The fee schedule should be accessible to patients if needed. For example, you may want to display it in the clinic in a noticeable location such as the reception area.

No, this scenario would be considered professional misconduct. The posted fees are not honest and accurate. The practitioner is, in effect, billing patients with insurance more than their actual regular rate.

Other

Insurance coverage is determined by the individual plan and policy. It is recommended that patients contact their insurance provider to confirm if a specific TCM treatment is covered by their plan.

The College is not in the position to comment on the specific practices of insurance companies. The patient will need to confirm this with their individual insurance provider.

Members must use their professional judgement on what treatments can be provided at this time to their patients. You will also need to exercise greater caution with treatments that have the potential to damage the skin, such as using PPE and thoroughly cleaning and sanitizing equipment between patients. For more information on cleaning and disinfecting equipment, please refer to the Safety Program Handbook.

Members must have the resources needed to support infection control procedures, which include:

  • Sinks, liquid soap, and alcohol-based hand rubs
  • Disinfectants
  • Personal protective barriers
  • Sharps disposal containers
  • Biohazard waste containers

Biomedical waste (not including sharps) should be disposed of in a designated biohazard waste container. In addition, any office staff managing the biomedical waste should wear protective apparel and be informed of relevant immunizations. Licensed medical waste handlers must be used to remove biomedical waste. For more information, please refer to the Waste Management section of the Safety Program Handbook. It is also recommended that practitioners check with their local municipal regulations for specific waste handling and segregation requirements.

It is expected that members use their professional judgment when making treatment decisions and to determine if the anticipated benefits of treatment outweigh the risks to the patient and the practitioner. For example, if the treatment involves the facial area, the practitioner needs to use their discretion to assess the risk of providing or continuing treatment. The risk assessment may also help determine if other PPE is necessary for the specific treatment, in addition to the COVID-19 requirements. For information about the PPE requirements, please refer to the COVID-19 Operational Requirements: Health Sector Restart and the Return to Practice Guidance Document.

As outlined in the Ministry of Health COVID-19 Operational Requirements: Health Sector Restart, members should require all patients to wear masks when arriving for or receiving treatment (including while patients are in a designated waiting area or room). Patients may wear non-medical face masks. These masks should have at least three layers and should completely cover the nose, mouth and chin without any gaps. For more information, please refer to Non-Medical Masks and Face Coverings.

It is strongly recommended to contact your local public health unit for direction on this situation. They will be able to advise you about any requirements for contacting patients and others who work in the clinic and for ensuring your clinic setting is safe.

In general, practitioners and their staff should continue to follow the COVID-19 Operational Requirements: Health Sector Restart for infection control, including screening, physical distancing, disinfecting, and PPE.

Practitioners exhibiting symptoms of COVID-19 should self-isolate and contact their local public health unit and primary care provider or Telehealth Ontario (1-866-797-0000).

Provided that the clinics comply with the requirements set out in COVID-19 Operational Requirements: Health Sector Restart, health care providers may practice at more than one location. The main concern in these situations would be the potential for exposure in one clinic and the possibility of spreading the infection to the other. You will need to check with clinic management to ensure that they have reviewed the requirements for risk assessments, hierarchy of hazard controls, screening, health human resources, critical supplies and equipment, infection control and other important issues.

We are unable to provide information on specific products and their effectiveness for disinfecting equipment. However, the College’s Safety Program Handbook has a list of formulas (including ingredients) for various levels of disinfection on pages 25 and 26. The Government of Canada published a list of hard-surface disinfectants and hand sanitizers that is regularly updated. Along with their DINs, there is a search function that allows you to filter for specific product or company names.

In addition, Public Health Ontario provides guidance on cleaners and disinfectants that are effective for use against COVID-19.

Key reminders

  • Use only disinfectants that have a Drug Identification Number (DIN);
  • Be sure to check the expiry date of products you use;
  • Follow manufacturer’s instructions on where and how to use a product.

Practitioners and their staff should be regularly self-monitoring for COVID-19 symptoms. If there is a concern that staff or practitioners were exposed (directly or indirectly), they are advised to self-monitor and self-isolate. Public Health Ontario has factsheets that can be used to educate clinic staff and patients regarding:

If a practitioner has screened positive, they should inform their supervisor immediately, if applicable. They should self-isolate and contact their public health unit and primary care provider or Telehealth Ontario (1-866-797-0000) for further direction. If staff are considered likely to have been infected as a result of workplace exposure, employers have a duty to notify the Ministry of Labour, Training and Skills Development for occupational illnesses.

Evidence that the practitioner obtained informed consent from the patient for the treatment. This could be in the form of a signed document (handwritten signature or digital signature) or a notation by the practitioner in the patient record setting out what was discussed. The written consent reassures the practitioner and the patient that the patient has provided informed consent so that the practitioner can provide the treatment.

Remember that the written consent is evidence that the patient provided informed consent. The actual informed consent is obtained by providing all of the necessary information to the patient, and answering all of the relevant questions from the patient.

Yes, the College has created a template consent form that includes sensitive areas. Please refer to the College's updated form.

While email and text messages may be convenient, practitioners have a legal and ethical responsibility to keep patient information confidential. Email communication may not always be secure and, as such not recommended for information that includes identifiable personal health information.

Further there is a risk that if there is a time lag between obtaining the consent and providing the treatment, the patient may have changed their mind or had additional questions. It is the responsibility of the practitioner to always ensure that the consent is still valid and that there have been no changes to the patient’s health as this could affect the possible risks of the treatment.

Yes. The information can be kept in digital format. Members must ensure all electronic records are kept securely (via password). If any information is being kept in a digital format, issues pertaining to the access of the files along with the storage of information should be considered (e.g., if using a cloud server, efforts should be made to ensure that information is kept in Ontario, etc.)

Remember that the signature on the consent form (or the written notation in the patient chart) is merely evidence that the patient provided informed consent. The member will want to ensure that they still have the consent of the patient to proceed. Sometimes it will be prudent to have the patient sign a new consent form. Sometimes it will be sufficient to verbally confirm that the consent is valid and document this in the patient chart. Consent is an ongoing process. Members should re-confirm consent at each visit. This will ensure that the practitioner has the consent of the patient to proceed. Further, there may be a change in the patient’s health over time. The change in health could affect the treatment provided by the Member. This is why it is important to ensure with the patient that the consent is still valid at each visit. If the practitioner confirms that there is no change in treatment plan, or the patient’s health, then the practitioner can simply indicate in the patient chart that the original informed consent applies. However, if there is a change in treatment plan, the Member will be required to obtain a new informed consent.

However, note that for treatment of sensitive body parts, the practitioner is required to obtain written consent for the initial treatment, and express (or verbal) consent for any subsequent treatments involving the same treatment plan. The practitioner should document that they obtained express consent in the patient record.

Written consent will be required for initial treatment of sensitive areas (upper and inner thigh, buttocks, penis, vagina, breasts and chest wall muscles). For future follow up visits, verbal or express consent is required. To maintain accuracy and comprehensiveness of patient records, verbal consent ought to be noted in patient records immediately after treatment.

If the treatment does not involve sensitive body parts, and the treatment plan has not changed, the practitioner can assume that the original informed consent is valid.

However, if there has been any change to the treatment plan or the patient’s health, a new informed consent is required. This is why it is prudent to verify with the patient at each appointment if they still provide consent to proceed and to check in on any changes to the patient’s health.

There is no minimum age of consent for healthcare in Ontario. As such, members should not make assumptions on capacity based on age. Rather members must assess each patient on their ability to understand the nature of the treatment being proposed, and the possible outcomes of consenting or not consenting to treatment.

Yes. The original consent would have involved a discussion of treatments, risks, alternatives, etc. that were specific to the original issue. If another issue or concern is raised, then this would require the member to obtain informed consent for that specific issue as different treatments, risks, alternatives, etc., will be discussed. This is necessary in order to ensure the consent is informed.

Written consent is merely evidence of the patient providing informed consent. If the treatment involves contact with a sensitive area, a practitioner must obtain written consent before beginning treatment. This would involve the practitioner having the necessary discussion with the patient first, going through all of the elements of informed consent and answering any relevant questions of the patient, and then asking the patient to sign the written consent form.

If the treatment does not involve contact with a sensitive area, the practitioner must still obtain informed consent as set out above. However, the patient is not required to sign a consent form. The practitioner may wish the patient to do so, but it is not required from the College. The practitioner may wish to simply note in the patient record that informed consent was obtained and set out the information that was discussed in order to obtain informed consent.

The Standard for Consent (which came into effect on April 1, 2020) requires a consent form for the initial treatment that involves contact with a sensitive area. Expressed consent can be used for follow up visits and treatments that do not involve contact with a sensitive area. It is not necessary for members to get consent forms signed retroactively (i.e., for treatments received before April 1, 2020).

Sensitive areas include the upper and inner thigh, buttocks, penis, vagina, breasts, and chest wall muscles. (Standard for Preventing Sexual Abuse).

This will depend on the part of the body being treated. If the treatment involves contact with a sensitive area, you must obtain informed consent (by discussing all of the relevant information) and then asking the patient to sign the written consent form before beginning treatment. If the treatment does not involve a sensitive body part, obtaining verbal informed consent is sufficient. However, it will be important for the member to document in the patient record that they obtained verbal consent. This is evidence of informed consent being provided by the patient.

No. The Regulated Health Professions Act , 1991 states that it is a controlled act to put an instrument, hand, or finger beyond the labia majora. Members of this College are not authorized to perform this controlled act.

Yes. The Standard for Preventing Sexual Abuse states that members should not touch the nipple or areola. It is the position of the College that providing TCM should not involve touching the nipple or the areola. Therefore, members should advise patients that they will not touch that body part.

The Standard for Consent requires written consent on the first visit for treatments with contact of sensitive areas. This is not required for treatments near the sensitive area; however, members should use their professional judgement for any precautions for treating these areas. For instance, members should ensure proper draping is maintained when treating near sensitive areas. (Safety Program Handbook, page 80-82)

Members must not provide services to a person with whom they have a sexual relationship, including spouses, except in an emergency. It is not recommended for the practitioner to treat other members of their family, as the practitioner will likely be unable to discharge their fiduciary duty in light of the emotional connection to the patient.

Members can accept gifts of nominal value from patients; however, gifts of high value may risk crossing professional boundaries. Members should consider whether receiving or providing a gift constitutes a conflict of interest. ( Jurisprudence Course Handbook, pg. 20-21, 64-65) Members need to be mindful that accepting a gift does not blur the boundary between the patient and the practitioner.

It is the member's responsibility to maintain professional boundaries. If a member is concerned that a patient's behaviour is posing a risk to those boundaries, the member must address the behaviour directly. If the member finds that it is not possible to maintain the professional boundary, they must take the steps to end the patient-practitioner relationship as outlined in the Standard for Maintaining Professional Boundaries.

It is the member's responsibility to maintain professional boundaries. If a member is concerned that a patient's behaviour is posing a risk to those boundaries, the member must address the behaviour directly. If the member finds that it is not possible to maintain the professional boundary, they must take the steps to end the patient-practitioner relationship outlined in the Standard for Maintaining Professional Boundaries.

The one year period is referenced in the Health Professions Procedural Code. Under the Code, practitioners must not engage in sexual relations with a patient or engage in sexual behaviour or make remarks of a sexual nature towards their former patients within one year after the date upon which the individual ceased to be the practitioner’s patient.

The College of Massage Therapist of Ontario (CMTO) requires written consent for treatment involving contact of a sensitive area. Unlike the College, the CMTO requires its registrants to obtain written consent before every treatment session that involves touching of the sensitive areas.

The webinar is equivalent to 1 hour of professional development activities and a certificate of participation was emailed to all members that joined in during the live stream.

Forms and Templates

The College developed the following standardized templates to help members meet their record-keeping requirements:

  • Patient Health Summary Form
  • Initial Assessment and Treatment Record
  • Follow-up Treatment Record
  • Consent to Treatment Form
  • Consent to Treatment Form (Sensitive Areas)
  • Consent to Collect, Use and Disclose Personal Health Information Form
  • Equipment and Supply Records

These record-keeping templates can be found under the Record Keeping Guideline tab on the Guidelines webpage. Practitioners have no obligation to copy and use the provided templates but may find them useful as a starting point for when they develop their own templates and record keeping practices. These templates are available for download and can be formatted to suit your practice needs and design. Members should be mindful that the templates will be edited over time, so they should ensure that their template is the current version offered by the College.

If a patient does not have a primary health care provider, the section can remain blank. Practitioners may wish to seek clarification when information has been omitted on patient forms. Practitioners may want to explain why this information is requested. This may alleviate the patient’s concern.

The name of the prescribed herb has to contain two sets of information:

  1. Chinese Characters (simplified or traditional) and/or Pin Yin; AND
  2. Medical Latinate or Botanical Name.

Practitioners should also record the type of herbs, the quantity of herbs, how to prepare them, how to store them and the frequency of treatment on the treatment form.

Maintaining proper records is important for practitioners and patients. Although the gage of needles used is not a requirement, it is considered best practice to maintain detailed patient notes. Complete and comprehensive records help with recalling a patient’s medical history and previous treatments. It also permits the patient to have a full picture of the treatment provided if they wish to review the treatment record.

All equipment used (including devices such as CPR equipment, scales and slicers) must be maintained according to the standards listed by their manufacturer or supplier. All relevant information should be maintained in a logbook.

Additionally, practitioners must detail, maintain and keep an inventory of:

  • Every instrument or equipment used for any service to patients;
  • Sterilization of equipment, if used (such as a cupping instrument and/or other equipment where blood is involved); and
  • Other equipment service records as necessary

The Follow Up Treatment Record is required for every follow-up visit. The Follow Up Treatment Record must contain the following information:

  • Date of visit
  • Progress inquiry
  • TCM differential diagnosis
  • Treatment plan modification
  • Contraindications
  • Herbal medicine prescription
  • Acupuncture prescription
  • Adjunct modalities/treatment or procedures used and specifics
  • Patient's reaction to treatment Document patient refusal to follow the recommendation.

If multiple treatments are provided during an appointment, they can be listed on the same form.

The requirement for members to obtain patients' consent for treatment is the same for telepractice and in-person patient care. However, in addition to the necessary components of consent, members should also inform their patients about the risks associated with providing services in ways other than in-person interactions. This will ensure that members obtain full and informed consent before providing treatment electronically. For more information, please see the Standard for Consent. Templates for consent forms can be found on the Guidelines webpage.

Record Keeping Responsibilities

Practitioners who practice in more than one regulated health profession must maintain separate patient records. Practitioners are expected to ensure that it is clear to their patients (and third parties, e.g., insurance companies) what profession they are practising at any given time and what type of service they are providing in that capacity.

For example, a CTCMPAO member who is also registered with the College of Massage Therapists of Ontario (CMTO) must maintain two completely independent patient records, one for TCM/Acupuncture and one for Massage Therapy.

Similarly, financial records for each profession must be maintained separately.

When a practitioner retires or leaves the practice (i.e., resigns as a member of the College), the original patient records must be kept for the ten-year retention period (unless the records have been transferred to another practitioner who will maintain the records).

The member needs to ensure that the patient has access to the patient chart for the ten-year window. This will require the member to maintain the patient chart in a safe and protected manner. It will also require the member to ensure that patients know who to contact if they wish to obtain their patient chart.

The Office of the Information and Privacy Commissioner of Ontario recommends custodians implement a succession plan to address changes in practice and prevent abandoned records. For more information, please see the Succession Planning to Help Prevent Abandoned Records Fact Sheet.

Also, as outlined in the College’s Safety Program Handbook, if there is a situation where the practitioner, using professional judgment, decides to terminate the practitioner-patient relationship, it must be done carefully and thoughtfully in order to ensure the health of the patient and the continuity of care needed for the patient. The practitioner must provide written notification to the patient, outlining the specific reasons for termination and the date that care will be terminated. This written notification must also be retained in the patient record. If applicable, the practitioner must identify the need for continued care and establish processes to allow for the efficient transfer of records to the new practitioner. 

You may wish to inform your patients of the availability of alternate members, which can be done by, for example, referring the patient to the College’s public register or providing them with other members’ contact information.

In situations where clinic staff maintain the cleaning schedules and records, practitioners are not required to keep a separate log. However, practitioners should be able to access these records when required. Practitioners also need to ensure that the cleaning and its regularity complies with the expectations of the College. Therefore, practitioners will want to ensure that designated staff members are fully informed as to what is required. At the end of the day, regulated members are responsible for this to occur.

Members must retain traditional Chinese medicine herbs and equipment records for five (5) years from the date of the last entry in the record.

A record should be kept of the inventory of herbs that includes:

  • identity of the herbs purchased
  • name of the wholesaler
  • country of origin (to manage any recalls due to adulteration of specific species)
  • date purchased

When a prescription is dispensed, a record (or copy) of the prescription must also be kept on file. This record must include:

  • ingredients of the prescription and amounts (should be on the copy of the prescription if it was made)
  • date the prescription was dispensed
  • number of packets dispensed
  • name and contact details of the prescribing practitioner (should be on the copy of the prescription if it was made)
  • name of the dispenser

For more information, please refer to Section 5 - Safe Procedures and Processes: Herbology of the Safety Program Handbook.

Members must retain patient health and financial records for ten (10) years from the date of the last patient visit.

For patients who are minors, records must be kept for ten (10) years after they turn 18.

Record keeping is an important part of every member’s practice. Members must maintain comprehensive records for every patient.

In some instances, there may be fees associated with record keeping. For example, when members transfer patient care to another provider, there may be costs for photocopying or scanning patient files.

However, members cannot charge patients for storing their records. That is a professional responsibility, and the cost must be assumed by the member.

The treatment record templates can be formatted to suit your practice needs. All diagnostic methods must be noted in the patient’s record. You may wish to include another section on the form to capture additional examination information. Accurate, clear and concise documentation helps to facilitate follow-up treatment and prevents error.

While records may initially be recorded in a language other than English or French, members must also translate their records into English or French soon after the original record is made. The College's Standard for Record Keeping states that records must be translated into one of the two official languages in a timely manner. This requirement applies to the entire patient record.

Members must be aware that requests for records can come at any time (from the College, other health care providers in an emergency, law enforcement, etc.), and it is the member’s responsibility to respond to those requests without delay. Failing to respond to a request for records in a timely manner because the records have not been translated could be considered a breach of the standard of practice. Therefore, members must have a procedure for translating records that allows them to respond to unexpected requests for records.

The College does not have a template for a privacy policy for clinic use.

The following list of resources below may be useful for practitioners or clinics that wish to develop a privacy policy:

Electronic Records

The College cannot recommend specific record keeping software. However, for records kept electronically, there must be backup files and restore protocols in place. Access to the computer records must be secured via password to avoid tampering.

The practitioner is responsible for the safety and care of the electronic files to avoid privacy breaches. This includes accountability in how the electronic files are stored (e.g., location of servers, local backups, and cloud storage).

The Office of the Information and Privacy Commissioner of Ontario has information on safeguarding personal health information stored electronically.

Generally, every patient has a right to access his or her own personal health information unless an exception applies. [For example, if access would significantly jeopardize the health or safety of a person. The Personal Health Information Protection Act, 2004 (PHIPA) section 52. includes a list of the exceptions].

Practitioners are expected to retain original patient records. If a patient requests access to their health records, members may provide a copy (photocopy or electronic) of their records to them and notify them of any associated fees.

Remember, practitioners must retain patient health and financial records for 10 years from the date of the last patient visit.

Financial Records

No, only the names of the practitioner and others involved in the care of the patient need to be included on the treatment invoice.

Members must provide receipts that accurately reflect the service provided and/or product sold. Receipts must clearly identify the member who provided the treatment. A record of receipts issued and payments received form the financial record.

Financial records must include receipts and/or invoices for any treatment, product, or administrative fee (e.g., appointment cancellation fee) a patient has been charged.

Members are reminded that receipts must be provided after each treatment. It is not acceptable to issue block receipts.

Invoices must be an accurate representation of the service provided to the patient. If applicable, an invoice should indicate that a service was provided outside of the clinic (e.g., in a patient’s home). Otherwise, the receipt will infer that the service was provided in the clinic as the address of the clinic will be the only locale information.

Consent