SOAP-notes-for-medical-massage-webYour communication skills are as important as your technical ability in medical massage.

You must have open, honest communication with clients, and if your practice is medically oriented, your communication with other members of the health care team are a vital part of your image as a professional massage therapist.

1. The Intake Form and Interview

The intake interview serves for you to gather information, and to help the client feel at ease. This is especially true in the case of a client who is new to massage and doesn’t know what to expect. The client needs to feel as if you are listening to them, and addressing any concerns they may have.

When conducting your intake, ask yourself, “does the question have any bearing on the massage I give them?”

Examples of inappropriate questions are:

  • Questions about spirituality or religious practices, as the answers are none of your business.
  • Questions about diet. Unless you’re a licensed nutritionist or dietician, it is outside a massage therapist’s scope of practice to give dietary advice.
  • Questions about use of alcohol, tobacco or other things you consider to be bad habits. If you think someone is under the influence of alcohol or drugs, you have the right of refusal, but if they are not under the influence during your session, it has no bearing on your massage. If you have an allergy to tobacco or just don’t want to work with smokers, you should tell everyone who calls for an appointment at first contact that you don’t accept clients who smoke.
  • Questions about their personal lives. That said, you may ask about their stress level.

If the question isn’t necessary to the treatment, you shouldn’t ask it.

Examples of what you should ask are:

  • The client’s contact information.
  • An emergency contact.
  • Why he is seeking massage therapy.
  • His medical history. You can be selective; while we need to know if someone had a surgery a month ago so we can avoid an area that is not healed, it’s not our concern that he had a tonsillectomy when he was a child.
  • If he has any allergies—particularly nut allergies—so you will avoid using nut oils. Some people are sensitive to essential oils, so don’t assume it’s OK for you to apply oils without asking.
  • What limitations his condition is causing them.
  • Whether there are any areas the client would like you to avoid touching.

Since the public is generally unaware of the contraindications for massage, avoid open-ended questions such as, “Is there any reason I shouldn’t give you a massage?” List the contraindications that would prevent them receiving massage or that would cause you to have to modify the session.

It may occur to the diabetic client to tell you she has diabetes—but she may forget to mention the peripheral neuropathy that she has as a result. You don’t want to give someone who is numb a hot stone massage, so when a client has a medical condition you need to know what follow up questions to ask related to the condition.

In some instances, the condition may not be a concern. Instead, the medications they’re taking may be. For example, blood thinners and platelet-altering drugs may cause the client to bruise easily. Other drugs cause brittleness of the bones, making them not a good candidate for deep massage. Clients undergoing chemotherapy may experience increased nausea and flu-like symptoms if they have their massage too soon after receiving chemotherapy. Additionally, radiation may leave the skin fragile.

It is your responsibility to be informed, and a thorough intake interview will help you accomplish this.

2. Assessment

Asking a regular weekly client, “Is there anything special you want me to focus on today?” is OK, but you must go beyond that for a new client. Question him about things he’s marked on their intake form, such as, “How long since your knee replacement?” and, “Has that made a difference in your pain and functionality?”

It’s common to ask, “On a scale of 1 to 10, how would you rate your hip pain?” However, it’s important to remember how subjective this is, and that your 10 is not the same as the client’s. It is better to find out how pain or range of motion limitations interfere with clients’ daily lives. Activities of Daily Living (ADL) indexes are good assessment tools for this purpose. Many ADL indexes are available free of charge online for back, neck and extremity pain.

Visual assessments of posture, gate and range of motion, along with palpation, intake information and mutual treatment goals, are the basis for the treatment plan.

3. Documenting Progress

SOAP notes should be detailed and specific. Remember that you will refer to these notes long after the massage. All relevant information should be included to provide better context in the future.

Example of an inappropriate SOAP note:

  • S: Client said she hurts.
  • O: Lots of tight muscles.
  • A: Did some work on her.
  • P: Told her to come back later.

This isn’t very informative, is it?

Example of an appropriate SOAP note:

  • S: Female, age 48, first massage. Factory worker; repetitive motion job. States constant pain in both arms, most severe distal from elbow.
  • O: Tender points in brachioradialis and all extensors, entire arm feels very taut. No ROM limitations.
  • A: Focused session on neck, shoulders, upper back and upper extremities. Client stated feeling much better at end of session.
  • P: Client agreed to weekly sessions for one month, then re-evaluation.

4. The Exit Interview

Leave enough time between appointments to offer the client water, the opportunity to use the restroom, and to see how she is feeling after the massage. Discuss a suggested treatment plan, keeping in mind you’re trying to meet the mutually agreed upon goals for the client.

Avoid promising anyone that you’re going to fix her, or making guarantees that her problem will be solved within a certain number of sessions. The safer course is to suggest several sessions, with re-evaluation.

The objective is to get the client to feel as well as possible, and to make massage a part of his or her regular wellness plan. Setting realistic goals and educating the client is part of that, and much better than promising quick results.

Serve Clients

Remember to incorporate professional communication skills into each massage session, to best serve clients and grow your practice. After “Thank you,” the most important thing to say is, “When would you like your next appointment?”

 

About the Author

Laura Allen is the massage division director of Soothing Touch, an author, educator and clinic owner. She has been a massage therapist for 16 years. She resides in the mountains of North Carolina with her husband, Champ, also a massage therapist, and their two rescued dogs. Visit her website at lauraallenmt.com

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