Massage & Bodywork

JANUARY | FEBRUARY 2021

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36 m a s s a g e & b o d y wo r k j a n u a r y/ fe b r u a r y 2 0 2 1 Let's get right to it with a truthful inquiry: Do you chart your sessions? If not, why not? If my experience with the unfortunate rarity of massage therapists who conduct a thorough health history intake is any indication of the number of therapists who are charting, the answer to the question is likely no. My goal, then, is to provide a wake-up call and perspective shift by illuminating the what, the why, and the how of SOAP charting, along with the possible consequences of skipping this essential step of your overall session. THE WHAT Charting (also called documenting) involves keeping a clinical record of the important details and facts about a client session, specifically a problem- focused session. While other methods have been developed, the SOAP (Subjective, Objective, Assessment, and Plan) format remains the most widely used among health-care professionals. Session details and facts include what a client says they are experiencing in their body and environment, what you see and feel when you observe and touch them, what you do during the session to address their concerns, and what your recommended plan is for making progress toward the client's goals. With that said, let me make a very important point: even if you are a wellness- based massage therapist whose primary focus is stress relief and relaxation rather than clinical concerns, you still need to be documenting each and every session. The SOAP format can be used with less detail, SOAP Charting The Lowdown on the Importance of Clinical Recordkeeping By Cindy Williams education | BACK TO BASICS because if you are doing a proper intake, you will still be asking what the client is experiencing and what they want from the session, observing their body language and posture, and noting what techniques were used within the massage. If you prefer a format other than SOAP for documenting a wellness session, go for it. The call to action here is "Just do it!" THE WHY No call to action is complete without some critical thinking. Let's face it, the likelihood you will surrender to the call on my urging alone is low (rightfully so). So, let's look at a few (of many) reasons why it is so important to chart a massage session. It promotes client safety and satisfaction. Safe therapists engage in behaviors that protect the well-being of their clients. When you listen to and chart their concerns, their limitations, their pain levels, their stress levels, what stressors they experience, what techniques they liked or didn't like, what depth of pressure they responded favorably to and in what areas, what techniques promoted the best results, and what exacerbated a condition or concern, you are priming yourself to provide a safe and effective environment for them on an ongoing basis. This is a cornerstone of exceptional, client-focused service. It promotes consistency and communication among other health- care professionals. Even if you don't currently work with other health-care professionals, what if someday you do? A client may present with a concern that worsens. Having a record of when the complaint began and how it progressed could be useful information for anyone who works with this client in the future. Of course, if you already work with a health-care team, it keeps everyone on the same page toward a common goal. It reveals progress. By documenting what you did and what changes the client experienced, you can plan future sessions more effectively by repeating what worked or changing course when an approach didn't provide relief. Again, even if you don't take a clinical approach, you might incorporate breathing or visualization techniques, essential oils, hot or cold packs, etc. All of these are worthy of observing the benefit. Plus, when you can show a client progression, their attitude toward the possibility of further progress supports their journey toward health. It protects the therapist in the event of a liability claim. Most liability claims involve a client's word against a therapist's word. But word alone is not enough. Being able to show in a professional, thorough, JOYCE MCCOWN/UNSPLASH

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