Issue link: https://www.massageandbodyworkdigital.com/i/1315831
L i s te n to T h e A B M P Po d c a s t a t a b m p.co m /p o d c a s t s o r w h e reve r yo u a cce s s yo u r favo r i te p o d c a s t s 37 well-documented manner what occurred on the date of the session in question may save you from paying a claim for which you might otherwise have been found negligent. Not to mention, if you haven't documented a session, the likelihood you would remember the date in question is low, especially if it occurred years prior. A little time spent charting now could save you a lot of time, money, and anguish in the future. THE HOW SOAP, again, is an acronym for Subjective, Objective, Assessment, and Plan. Concerns have been raised in the massage therapy profession regarding the use of SOAP charting, most notably a lack of understanding of the meaning and use of each section of the SOAP form. In an effort to create consistency, the following overview is adapted from Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists, 5th edition (Thompson, 2019). I highly recommend this book for complete information on session documentation, from start to finish. Subjective Data (what the client tells you) Health History. A SOAP chart for an initial session will include health history information along with current concerns gathered from the intake form and client interview. Subsequent sessions will record changes from the previous session and ongoing status of current concerns. Symptoms. This includes the location, onset, duration, frequency, and intensity of the symptom(s). If the client is in pain, note their precise level of pain on a measurable pain scale. It's also of significant value to document emotional implications of these symptoms. Functional Limitations. This refers to the limitation of daily activities, including cooking, cleaning, job performance, child care, sleeping, walking, grocery shopping, exercising, etc., due to their current concern and associated symptoms. Include activities that both aggravate and relieve their symptoms. Objective Data (what the practitioner observes before and after the session) Visual and Palpation Assessments. Visual includes breathing patterns, movement patterns and restrictions, postural asymmetry, and overall vitality. Palpation includes tissue texture, tone, temperature, and hydration. Special Movement Tests. This may include gait assessment, range of motion assessment, or orthopedic assessments within scope of practice (such as Phalen's test for carpal tunnel syndrome). Method of Treatment. Report what techniques were used, where specifically you used them, to what depth, and for what duration. Client Immediate Treatment Response. Note if the quality of tissue changed, if skin coloration changed, if heat increased or decreased, and/or if range of motion improved, for example. Assessment Data (precise functional goals and analysis of treatment effectiveness toward those goals) If a client reports during the subjective data section that they can only stand up to cook dinner for 15 minutes before their pain increases from a four to a seven on a 0–10 pain scale, their goal might be to increase that time to 20 or 30 minutes within a six-week period of weekly treatments. Chart progress toward that goal here based on what you performed in the objective data section. Plan (practitioner recommendation for ongoing treatment and self-care) This might look like "Weekly 30-minute massage to low back and hips for six weeks. Apply ice to low back 3 times a day for 10 minutes each round." THE LOWDOWN I recognize paperwork isn't fun, but it is necessary. It will make you a safer and more effective therapist, keep your client on track toward a healthy and vital life, and cover your bum should anything go wrong. There may be inconsistencies between sources on what gets documented under which heading, or if a different method of charting is more useful. In the end, though, as long as client concerns, symptoms, and goals, and practitioner pre- and post-treatment findings, approaches, and recommendations are measured and recorded in a clear and concise manner, the session will be well documented. If working with a health-care team and you are in doubt of their preferred format, just ask. Since 2000, Cindy Williams, LMT, has been actively involved in the massage profession as a practitioner, school administrator, instructor, curriculum developer, and mentor. She maintains a private practice as a massage and yoga instructor. Contact her at cynthialynn@massagetherapy.com. 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.