Session Record Guidelines

for Registered Canadian Reflexology Therapists (RCRT™)

Click on the button below to download our guidelines on contraindications.

download BY-LAWS reflexology

These guidelines provide a detailed framework for completing session records in a professional, consistent, and client-centered manner. Proper documentation supports ethical practice, continuity of care, and professional accountability. These guidelines align with the RAC Documentation Guidelines and Employment Contract Guidelines.

Overview

Each reflexology therapy session must be documented in a clear, organized, and comprehensive format. The session record should reflect every key stage of the appointment process and include both client-reported and therapist-observed information. Session records may be handwritten or digital but must remain secure and legible.

1. Session Record Structure

For the current RAC session record template, please refer to: Session Records.

Session records are both professional and legal documents. At a client’s request, they may be submitted as evidence in an injury claim. For this reason, they must be legible, clear, and complete.

Session records should be organized around the following five stages:

A. Pre-Appointment

  • Pre-screening questions (e.g., illness, infections, recent health concerns)
  • Note if screening was conducted in advance (e.g., phone, intake form)

For the current RAC pre-screening questionnaire, please refer to: Pre-screening Questionnaire.

B. Pre-Reflexology

  • ✔ Initial observations (e.g., gait, posture, energy, mood)
  • ✔ Feedback from the prior appointment (use client quotes where possible)
  • ✔ Health changes since the last visit (e.g., new diagnoses, medication, stressors)
  • ✔ Current state of health and mood (as reported by the client)
  • ✔ Client’s focus or goals for the reflexology session or treatment plan
  • ✔ Assessment of the Reflexology area(s) to be worked (e.g., skin condition, temperature, tension)
  • ✔ Contraindications and modifications, if any
  • ✔ Document any updates to the health history form
  • ✔ Outline session plan (areas of focus, goals, considerations)

For the current version, please refer to: Health History Form.

For guidance on identifying and responding to contraindications, including when to refer or modify the session, refer to RAC’s Contraindication Guidelines.

C. Reflexology Session

  • ✔ Confirm and document informed consent for the session, along with acknowledgment of confidentiality..
  • ✔ Techniques applied (e.g., thumb walk, pressure, sequence)
  • ✔ Client reactions and verbal comments during the session
  • ✔ Notable tissue response, temperature changes, or tension shifts
  • ✔ Record of any deviations from typical protocol
  • ✔ Use of diagrams or charts may supplement written notes

D. Post-Session

  • ✔ Systems and reflex areas focused on during the reflexology appointment
  • ✔ Client’s verbal feedback and reflection on the reflexology session
  • ✔ Indicate whether client’s session goal was addressed
  • ✔ Follow-up plan and session frequency recommendation

E. Post-Appointment

  • ✔ Therapist’s professional notes and final reflections on the session (e.g., departure observations, self-evaluation)
  • ✔ Session records may also include occasions when the RCRT™ referred the client to another RCRT™, Reflexology therapist or healthcare provider or concluded that it was not safe to proceed with reflexology therapy during that session.
  • ✔ Final observations (e.g., change in energy, demeanor on departure)
  • ✔ Notes about materials exchanged (e.g., referral letters, consent forms)

2. Session Record Requirements

1. For Initial Appointments:

  • ✔ Client’s overall and session-specific goals, including clear goals and expected outcomes for any multi-session therapy plans
  • ✔ Summary of intake review (if not recorded separately)
  • ✔ Complete documentation of session techniques and reactions
  • ✔ Duration of session and date
  • ✔ RCRT™ signature or initials (consistent usage throughout document)

2. For Follow-Up Appointments:

  • ✔ Feedback about prior session results
  • ✔ Client’s stated intention or focus for the day
  • ✔ Health changes or new contraindications
  • ✔ Any updates to the session plan
  • ✔ Observations during treatment and client response
  • ✔ Post-session outcome and client feedback
  • ✔ Follow-up strategy
  • ✔ RCRT™ initials or signature

3. Format, Storage, and Efficiency

  • ✔ RCRTs™ may develop their own glossary of symbols or color-coding systems to aid in efficient documentation. These systems must be clearly defined at the start of each client file and/or included within the documentation system (digital or paper) in use.
  • ✔ Records must be legible, factual, and written in professional language
  • ✔ Do not interpret or diagnose – quote client language when possible
  • ✔ Store records securely in accordance with provincial and federal privacy legislation
  • ✔ Retain records for the required period in your jurisdiction
  • ✔ Ensure only authorized individuals access session documentation

These guidelines are to be followed alongside RAC’s Scope of Practice, Standards of Practice, Documentation Guidelines, and applicable health record regulations in your province or territory.