As more Americans seek sessions from practitioners of integrative medicine, including massage therapists, the ethical, legal and professional obligations for thorough client health care records become more important.
Practitioners need accurate charts to keep track of a client’s progress, support continuity of care within a health care team, document proof of service and avoid malpractice cases.
SOAP (subjective, objective, assessment and plan) notes are an integral part of the vocation of massage therapy. Massage therapists rely on SOAP notes to help create long-term plans for client care, and insurance companies insist on them in order to process reimbursement.
In the case of a lawsuit, extremely organized, printed SOAP documentation will support the therapist. Comprehensive note-taking and features that prohibit the therapist from reopening and changing a note will help a therapist accused of malpractice. With electronic charting, SOAP notes are secure, date-stamped, legible and thorough.
With the passing of the Affordable Care Act (ACA), medical facilities and physicians are required to provide clients with electronic medical records (EMRs). There are no formal requirements stipulated for massage therapists related to charting under the ACA; however, that does not mean such charting will not be mandatory in the future.
The subjective section of a note includes the client’s complaints and symptoms; in the client’s own words, or issues that may have been discussed by a prescribing physician or other health care practitioner.
This includes: everything the client tells the therapist about how he is feeling; his past history and present symptoms; limitations in his life due to injury; what makes him feel better or worse; and details about initial onset of a problem or injury.
It is often helpful to ask the client to rate his pain or discomfort on a scale of 1 to 10, with 10 being worst. If you do this each session, you will be able to see improvements or setbacks.
Include answers to specific questions regarding location, intensity, duration and frequency of pain or discomfort. Have the client point to the specific area on his body or a body chart. Asking specific questions will lead to a clearer picture of the problem you are addressing.
The objective section of a note includes the practitioner’s observations and techniques that were done during the session.
This section includes visual observations and what the therapist feels when palpating the client. Included are: observations about the client’s posture, patterns and movement; weakness; level of tension in tissues; spasms in muscles; joint movement; color and temperature of skin; and breathing patterns.
The therapist can also test range of motion in different areas and keep track of the client’s improvement or changing patterns.
The assessment section of a note is where massage therapists, who are not allowed to diagnose, report the immediate results of the session.
At the end of the session, the therapist should reanalyze the client’s posture and range of motion. Include notes on any changes in symptoms, and indicate how much change happened—mild, moderate or significant change. Use as many descriptive words as possible.
Most insurance companies will take this information into consideration when paying for treatment. This is what informs them the client is getting better and massage treatment is worth reimbursement.
The plan section of the note is where the therapist will suggest treatment frequency and issues that need to be addressed in the future.
The therapist should include any self-care instructions given to the client, special requests by the client, or reminders for the next session.
In our massage clinic, we have had many challenges with paper SOAP notes. The charts were difficult to read. Abbreviations were not consistent between therapists, which caused a lot of confusion.
When a physician or insurance company requested a chart, we worried about the quality of photocopies. Charts were filed incorrectly on occasion, which caused widespread panic. The filing cabinets began to consume our reception space.
Another issue we had was getting clients to fill out a health-history intake form before their appointment began. Clients would show up at the office at 2:25 p.m. for a 2:30 p.m. appointment and be given a clipboard to fill out their medical history.
Elderly clients with lengthy histories would take 10 to 15 minutes to fill out forms, and their appointment would then not start on time.
Our solution to these problems was to develop a web-based charting program. Completing SOAP notes is still not a labor of love; however, it’s not the nagging duty it once was.
Just having the ability to email an intake form to a client when he made his appointment saved valuable time before the appointment began, and provided the therapist time to familiarize herself with the client’s conditions before he arrived.
The new generation of SOAP charting is a simple process. Online programs allow a massage therapist to chart anywhere there is an Internet connection.
There are apps designed to allow practitioners to complete notes on a tablet or smartphone. If the therapist provides on-site or corporate massage, electronic charting is an alternative to carrying files from one place to another.
Some programs allow therapists to tag diagrams and describe signs and symptoms in one or two clicks.
Whether you still use paper notes or make the move to online SOAP charting, proper documentation protects therapists, increases professionalism and helps ensure excellent continuity of care for clients.
About the Author
Mary Ellen Logan is co-owner of the Ontario College of Health & Technology in Stoney Creek, Ontario, Canada, and has been involved in massage education since 2004. She is also a director of SOAP Vault, a Web-based charting program for massage therapists and other health care practitioners.
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