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Q: “What’s the point of SOAP charting? Should I be doing this for all my clients?”

When it comes to charting wisdom, we’ll start with Alice Funk, a nurse and massage therapist in Lake Charles, Louisiana, with 26 years’ experience in patient care.

“I think everybody in the massage business should SOAP [chart],” Funk says.
“Even if you’re working in a spa, you never know if you’re going to need it for protection. Of course, the depth of your charting depends upon your environment. In a spa, all you may do is a quick history and chart the music and lotion preference of your client. But by not charting, you do the profession no help. You can’t prove what you did with your hands in a court of law. All you have is what you charted. Write it down. It’s your contract between the client and yourself.

“When you categorize and fine-tune the information you get in your intake, you can set up a plan,” she continues. “Sure, you can go and do a massage without a plan, but how do you tailor it to the client’s needs?”

Funk explains how a massage therapist can think carefully about each step of the intake process and then apply it to a very specific plan.

“SOAP” stands for Subjective Objective Assessment Plan. According to Funk, the subjective means “What is the client telling you?” The objective stands for the data the therapist takes in from palpation. The assessment is where the therapist evaluates what she or he is doing. Plan refers to what the client’s next session will consist of, and any homework given to the client.

“This process keeps you in tune,” Funk says. “It sets a focus, forces you to deliver to the client exactly what they came to you for. It’s also an evaluation of what you said you’d do.”

Another nurse/massage therapist, Susie Ogg-Cormier, from Lafayette, Louisiana, has practiced massage and nursing for 10 years each and has written a manual on hospital-based massage.

She concurs with Funk’s opinion that all massage therapists should SOAP chart. “The most obvious reason is that most states that require licensure also require documentation; it’s a state-mandated requirement,” Ogg-Cormier says. “Professionalism is another good reason. You increase your professional status and networking with other health-care providers if you can offer proof of care. This increases your accountability to meet health-industry standards – especially when working with physicians or in a hospital setting.

“Another reason [to chart] is evidence of safe practice,” Ogg-Cormier continues. “We need to have evidence that we evaluated the client’s particular circumstance for the particular kind of massage they received.”

To learn SOAP charting, Ogg-Cormier recommends the book, Hands Heal: Documentation for Massage Therapy, A Guide to SOAP Charting, by Diana L. Thompson.

“The book is pretty much the classic. It’s very much oriented toward the medical model and networking model,” Ogg-Cormier says. “But it’s a little more cumbersome for massage therapists who aren’t seeing those types of clients. If you’re in the spa industry, you don’t need that depth of charting.”

– Charlotte Michael Versagi, L.M.T., N.C.T.M.B., is a journalist and a massage therapist who specializes in manual lymph drainage and work with clients with cancer.

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