Before the beginning of a massage session, documentation is typically provided by a client to the therapist. In conjunction with a verbal interview, the therapist takes this information and determines what methods or techniques to use during the massage to fulfill the client’s goals. This initial documentation also enables the therapist to determine if there are any contraindications that may cause the therapist to avoid an area of the body or decline to conduct a massage at all. Once the massage has concluded, a therapist can write down their factual, objective observations made during the massage to see if the client’s goals were achieved and if so, by which particular techniques. There are general guidelines by which therapists should document information when information is not being recorded electronically. These guidelines include: ● Write legibly : Documents that cannot be read are of no use to the therapist, especially not as a legal document. ● If an error is made, it should be crossed out with a clean, straight line and initialed just above the end of the word or phrase : When correcting or adding information to Documentation formats There are several documentation formats used by massage therapists. The most common format therapists follow are SOAP notes, followed by APIE notes. These notes are primarily written after a massage has concluded. They can be used in conjunction with an intake form to accurately detail a client’s health status pre- and post-massage. Together, these notes help a therapist plan a current session as well as plan future treatments. The intake form A client’s intake form is used to ask for the client’s health history and the current status of their health. The form should begin with the client’s personal information at the top of the page. The information given here may include contact information such as an address, email address or phone number (for scheduling, confirmation calls or to resolve billing issues), an emergency contact phone number (in the event an emergency arises during a massage), or a client’s occupation or hobbies (as either may strongly influence a client’s soft tissue problems). Other information may include whether a client has had massages before, general pressure preferences, whether they might have any difficulty lying face down (prone) or face up (supine), and the client’s goals for the massage (their reason for scheduling an appointment). The intake form should also come with a checklist that a client can tick off for certain conditions, such as allergies, a fever, diabetes, high or low blood pressure, medications, osteoporosis, or any recent injuries. A blank space might be provided on the intake form for the client to write-in any condition not listed among the checklist that the therapist should know about. Below or alongside the checklist should be a diagram of the human body where the client can circle areas of their body that the therapist should inquire about during the interview portion of the intake process. Finally, a paragraph addressing informed consent – permission for a therapist to perform a service while detailing some of the benefits and risks of massage and the specific guidelines for a therapist’s and client’s behavior at the bottom of the intake form above where the client is required to sign their name. All of this information will be used during the interview process and reviewed later in this course. SOAP notes SOAP notes are used mostly to chronicle a client’s post-massage information and are typically found on the back side of the client’s intake form. SOAP itself stands for Subjective, Objective, Assessment and Plan. The Subjective portion of SOAP notes pertains to any information a client gives a therapist, whether in writing on the intake form or verbally during the interview before the massage. In relation to verbal information, direct quotes from the client may be written in this portion of the therapist’s notes. For example, the client may say, “When I raise my arm forward, the pain is a level 7” (on a 1-10 pain scale, discussed
something a client has written on an intake form, the words or phrases used by a therapist should be in a different color ink (black or blue) and initialed at the end. ● Use black or blue ink and do so consistently throughout a particular document : This separates originals from copies and prevents speculation about changes to a legal document. ● Be precise and succinct about terminology : Use terminology that is consistent through a range of disciplines; the names of muscles, for example, does not vary from discipline to discipline. ● Be careful with shorthand : Some acronyms are easily confused with others since they are not always similar across multiple health disciplines. For example, TP can stand for either ‘transverse process’ or it may stand for ‘trigger point.’ ● Avoid putting in writing or verbally giving a client a diagnosis : Diagnoses are only given by advanced health practitioners such as physical therapists or physicians. Diagnosing is outside the scope-of-practice for a massage therapist. later). Any information a client gives a therapist that the therapist hasn’t verified visually or through touch goes in the Subjective portion of SOAP notes. By contrast, Objective information is considered to be the facts discovered by the therapist during the massage. Facts may include what muscles are either: hypertensive or hypotensive, muscle spasms, restrictions, increases or decreases in range-of-movement, bruises, cuts, rashes, skeletal irregularities or areas of swelling. Information written down in the Objective portion of SOAP notes may confirm a client’s subjective information or add new information the client was unaware of. The Assessment portion of SOAP notes documents the effects of the therapist’s techniques upon the client; namely, the specific techniques which enabled the therapist to fulfill the client’s goals and which techniques did not. Changes to a client’s physical status are recorded here and should be listed in order of their effectiveness. For example, a therapist may write that “Petrissage decreased HT (hypertension) of the L (left) upper trapezius (muscle).” In the last portion of the SOAP notes, a plan is detailed by the therapist for either the client’s self-care, the client’s next appointment, how often a client should get a massage to manage their condition, or all of the above. Examples of a client’s self-care may include hot or cold compresses to relieve tight muscles, or manage pain and swelling. There can also be suggestions for stretching particular muscles or stress relieving techniques. Details about a client’s next massage in the plan portion of SOAP notes may include a suggestion for a longer session or resuming techniques that were effective in the present massage and discarding those techniques which did not further a client’s goals. The plan might also suggest how often a client gets a massage, though such a suggestion is open to the opinion of the therapist based on their training and experience. APIE notes APIE notes are similar to SOAP notes but with some slight modifications. The ‘A’ in APIE notes stands for Assessment and contains subjective and objective information prior to the massage being conducted. Note that the pre-massage objective information is assessed before the therapist actually touches their client; this information may change later in the Evaluation segment of the APIE notes. ‘P’ stands for Plan in APIE notes, meaning the therapist is going to detail what they plan to do in the massage and possibly future appointments as well. ‘I’ is for Implementation and is written after the massage to describe the techniques used for that day’s massage. Last, ‘E’ is for Evaluation, in which the therapist decides whether the techniques described in the Implementation were effective in treating the client. APIE notes are not as commonly used as SOAP notes among massage therapists, but may be
EliteLearning.com/Massage-Therapists
Book Code: MLA1224
Page 96
Powered by FlippingBook