Washington State Rules for Breast massage
to be adopted into law on July 30, 2017.
as distributed via email by the Board of Massage on July 7, 2017
FROM THE DEFINITIONS SECTION:
(7) "Breast massage" means the specific and deliberate manipulation of breast tissue. Massage of the surrounding chest and shoulder muscles such as massage of the intercostal, pectoral, or axillary muscles is not considered breast massage. Breast massage is only allowed as authorized by WAC 246-830-555.
STANDARDS OF PRACTICE - LIMITATIONS RULE
WAC 246-830-550 Standards of practice—Limitations.
(1) It is not consistent with the standard of practice for a massage therapist to touch the following body parts on a client or patient:
(a) Gluteal cleft distal to the coccyx, anus and rectum;
(b) Inside the mouth unless an intraoral endorsement has been issued;
(f) Vagina, to include:
(ii) Labia (majors and minors);
(iv) Urethra; or
(g) Breasts, unless in accordance with WAC 246-830-555.
(2) A massage therapist must maintain evidence of the completion of at least sixteen specialized in-person contact hours of education and training if they are performing massage in the perineal area in addition to obtaining prior written and verbal informed consent. This written consent may be included within an overall general consent to massage document, if clearly delineated and either specifically initialed or signed.
(3) A massage therapist must not engage in sexual misconduct as described in WAC 246-16-100. Sexual misconduct will constitute grounds for disciplinary action.
THE BREAST MASSAGE RULE:
WAC 246-830-555 Breast massage
(1) Prior to performing breast massage, a massage therapist must:
(a) Acquire a prior signed written consent. The written consent for breast massage may be included within an overall general consent to massage document, if clearly delineated and either specifically initialed or signed. The written consent must:
(i) Be maintained with the client or patient's records;
(ii) Include a statement that the client or patient may discontinue the treatment at any time for any reason;
(iii) If the client or patient is under eighteen years of age, prior written consent must be obtained from a parent or legal guardian; and
(iv) Include a statement that the client or patient has the option to have a witness present, and that the witness must be provided by the client or patient.
(b) Use appropriate draping techniques as identified in WAC 246-830-560.
(2) In addition to the requirements identified in subsection (1) of this section, a massage therapist must maintain evidence of the completion of at least sixteen hours of specialized in-person education and training in breast massage beyond the minimum competencies. Education and training in breast massage includes, but is not limited to: Breast anatomy and physiology, pathology, indications, contraindications, therapeutic treatment techniques, draping, appropriate therapist-client or patient boundaries, expected outcomes, and client or patient safety related to breast massage.
(3) In addition to the requirements in subsections (1) and (2), prior to performing a massage of the nipples and areolas, a massage therapist must obtain additional documentation as follows:
(a) A written prescription or referral from a licensed medical health care provider for this specific treatment; or
(b) An additional prior written and verbal informed consent from the client or patient for massage of the nipple and areolas. This written consent may be included within an overall general consent to massage document, if clearly delineated and either specifically initialed
THE DRAPING RULE
WAC 246-830-560 Coverage and draping
(1) A massage therapist must:
(a) Allow a client or patient privacy to dress or undress except as may be necessary in emergencies or custodial situations; and
(b) Always provide the client or patient a gown or draping except as may be necessary in emergencies.
(2) Massage therapists must use safe and functional coverage and draping practices during the practice of massage when the client or patient is disrobed. The drape(s) must be sufficient to ensure the genitals and the gluteal cleft distal to the coccyx, anus and rectum are not exposed, and the breast area is not exposed except as allowed in subsections (3) and (4) of this section. Safe and functional coverage and draping means:(a) The massage therapist explains, maintains and respects coverage and draping boundaries; and(b) Massage or movement of the body does not expose genitals or gluteal cleft distal to the coccyx, anus and rectum, or does not expose the breast area except as allowed in subsections (3) and (4) of this section.
(3) With prior written, verbal, and signed informed consent of the client or patient, the gluteal and breast drapes may be temporarily moved in order to perform therapeutic treatment of the area. In addition, with informed and written consent, a client or patient may choose to have their upper torso undraped during the entire massage.
(4) If variations to this coverage and draping rule occur, a massage therapist must:
(a) Maintain evidence of education and training in specific modalities that require variations in coverage and draping;
(b) Receive voluntary and informed consent of the client or patient prior to any variation of coverage or draping; and
(c) Document in the client's or patient's record the rationale for any variation of coverage or draping.
(5) Any written consent required by this section may be included within an overall general consent to massage document, if clearly delineated and either specifically initialed or signed.
THE RECORD KEEPING RULES
WAC 246-830-565 Recordkeeping
(1) A massage therapist providing professional services to a client or patient must document services provided. Documentation should be appropriate to the venue, the type and complexity of those services and, when applicable, in sufficient detail to support and enable anticipated continuity of care. The documentation must include:
(a) Client or patient name and contact information or name and contact information of a parent or guardian if a client or patient is a minor;
(b) Age of client or patient;
(c) Health history sufficient to ascertain if there are cautions or contraindications to safe application of massage therapy, and an update of the current health status at each session;
(d) Date massage therapy is provided and the duration of treatment;
(e) The types of techniques and modalities applied;
(f) The location or areas of the body that received massage therapy;
(g) Written consent to treat;
(h) If breast massage is performed, an additional written consent to treat per WAC 246-830-555, and documentation of a therapeutic rationale;
(i) If breast massage of the nipples and areolas are involved, documentation of the prescription or referral per WAC 246-830-555 (3)(a), or an additional written consent to treat per WAC 246-830-555 (3)(b);
(j) Documentation of any written consent or any modification in coverage and draping as required by WAC 246-830-560; and
(k) For massage therapy where the focus is on treating a health condition, the following additional information is required:
(i) Symptoms, for example, pain, loss of function, and muscle stiffness;
(ii) Evaluation and findings, for example, movement, posture, palpation assessment and findings;
(iii) Outcome measures, for example, improvement in symptoms, movement, posture, palpation, and function;
(iv) Treatment plan for future sessions; and
(l) If performing massage in the perineal area, an additional written and verbal informed consent to treat per WAC 246-830-550(2).
(2) Client or patient records must be legible, permanent, and recorded within twenty-four hours of treatment. Documentation that is not recorded on the date of service must designate both the date of service and the date of the chart note entry. Corrections or additions to the client's or patient's records must be corrected by a single line drawn through the text and initialed so the original entry remains legible. In the case of computer-organized documentation, unintended entries may be identified and corrected, but must not be deleted from the record once the record is signed and completed or locked. Errors in spelling and grammar may be corrected and deleted.
(3) Correspondence relating to any referrals by other health care providers concerning the diagnosis, evaluation or treatment of the client or patient must be retained in the client or patient record.
(4) Client or patient records should clearly identify the massage therapist who is the provider of services by name and signature or electronic signature and date of service.
WAC 246-830-570 Record retention
(1) A massage therapist who treats clients or patients eighteen years of age and older must keep client or patient records for at least three years from the date of last treatment.
(2) A massage therapist who treats clients or patients under the age of eighteen years old must keep client or patient records for at least three years after the client or patient reaches eighteen years old.
(3) A massage therapist must also comply with record retention requirements of chapter 70.02 RCW.
(4) All records must be secured with properly limited access in compliance with chapter 70.02 RCW and the Health Insurance Portability and Accountability Act (HIPAA).
(5) After the retention period, the massage therapist may dispose of the record. Disposal must be done in a secure and confidential manner in compliance with chapter 70.02 RCW and HIPAA and must include as appropriate:
(b) Deleting, erasing, or reformatting electronic media; and
(c) Other readable forms of media that are defaced or rendered unusable or unreadable.
DOWNLOADABLE CONSENT FORM
Click the green button below to view, and optionally download, a form I created to document the client's consent for treatment of vulnerable areas. This form satisfies the multiple consent and documentation rules in Washington State related to the draping and/or massage of the chest/breast, and also of the pelvic floor.
Although the rules do not specify whether written consent is required for each session or only on the initial intake form, to support safety I have created the form with space for the client to initial their consent at each session.
Feel free to modify this form as needed to use in your practice. If you would like a copy in WORD, click here to sent me a request.
breast massage laws in Washington state
until July 29, 2017
See next section of this page for changes to the law that are scheduled to be implemented in July 30,2017.
In Washington State there are currently no breast massage or draping rules which specifically govern massage therapists within the RCW laws (written by the legislature) or WAC rules (written by the Board of Massage within the Department of Health).
The following rules for draping and touching the breasts apply to all health care providers licensed by the Department of Health. These rules are located in code for the Department of Health, Standards of Professional Conduct, Sexual Misconduct. http://app.leg.wa.gov/wac/default.aspx?cite=246-16-100
(1) A health care provider shall not engage, or attempt to engage, in sexual misconduct with a current patient, client, or key party, inside or outside the health care setting. Sexual misconduct shall constitute grounds for disciplinary action. Sexual misconduct includes but is not limited to: …
(b) Touching the breasts, genitals, anus or any sexualized body part except as consistent with accepted community standards of practice for examination, diagnosis and treatment and within the health care practitioner's scope of practice;
(h) Not providing the patient or client a gown or draping except as may be necessary in emergencies;
The rules mention "accepted community standards of practice for examination, diagnosis and treatment within the health care practitioner's scope of practice." There are various opinions within the massage community of what constitutes acceptable breast massage. There are no officially agreed upon community standards for breast massage by massage therapists.