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SOAP Charting for Massage Therapists
Please also check the
insurance billing manual updates and the
blog for more information.
Subjective: The client's subjective complaints and symptoms that are in the clients own words or may have been discussed by the prescribing physician. This includes all the things the client tells you about how they are feeling, past history, present symptoms, limitations in their lives due to the injury, what makes them feel better or worse, and details about the initial onset of the problem or injury. It is often helpful to ask the client to rate their pain or discomfort on a level 1-10 with 10 being the worst. If you do this each time, you will be able to see improvements or setbacks. Ask specific questions as to the location, intensity, duration and frequency of the pain or discomfort. Have the client point to the specific area on their body or body chart. Ask how painful is it? How long have they had it? Hours? Weeks? Months? Longer? Has it been worse or better? What makes it worse or better? How often do they get it? Every day? Once a week? Asking specific questions will lead to a clearer picture of the problem/injury you are treating. Objective: This is the observations of the practitioner and what techniques were done during the session. This includes visual observations and what you feel in the body of the client. Include things you observe about the client’s posture, patterns, movement, weakness, level of tension in the tissues, spasms in muscles, joint movement, color/temperature of skin and breathing patterns. You can also test the range of motion in different areas and keep track of their improvement or changing patterns. Some common findings are defined below: Hypertonicity: involuntarily tight or contracted muscle; excess muscle tone; the tension of the resting muscle is unusually high. Spasm: involuntary contraction of a muscle as a protective response to an injury or trauma. Trigger point: specific point that refers pain Adhesion/scar tissue: the resulting tissue from the wound healing process causing a restriction in resiliency of the tissue Measure everything! That way you can show improvement as needed to show medical necessity. Assessment: Assessment usually involves collecting the information from the subjective and objective part to make a diagnosis or prognosis on the clients’ condition. Since massage therapists are not allowed to diagnose, the assessment is to report the changes that occur in a session. This is to report the immediate results of the session (functional outcomes). At the end of the session reanalyze the posture and range of motion. Make notes on any changes in symptoms. 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 the treatment. This is what is telling them if the client is getting better and is the treatment worth it. You can include here the doctor’s diagnosis. The Assessment section of chart notes is confusing. When I asked the WA State Board if we were allowed to assess a client’s condition, I was told yes. If assessment is making a diagnosis, then it is outside our scope of practice. The Assessment section comes from the SOAP notes format of physical therapists and other health care professionals who are able to diagnose. I propose that massage therapists need their own form of charting that is less confusing. Plan: Suggest a treatment frequency and things that need to be addressed in the future. Include any self-care instructions you gave to the client, special requests by the client, or reminders for the next session. You can include your goals for the client- what results do you expect or what you think the outcome will be. The physician usually provides treatment plans that include how many sessions and how often sessions are to be given and what areas are to be worked on. Insurance companies need to see improvement in a client to verify “medical necessity”. One method of showing this is to include “functional outcomes” in your SOAP notes. Functional outcomes are the improvements in function that occur as a result of your massage. To chart functional outcomes you must first find out what functions are limited. Start with the basics like walking, turning their head, sitting, standing. Do the have functional limits due to their condition? You can then chart the progress of how their function has improved as a result of the massage. Insurance companies in general, don’t really care about pain levels, hypertonicities and spasms. They often assume that the client will have to live with a certain amount of pain. This is one of my professional concerns. Do we as a profession even want to be dealing with such companies? Decreasing pain, does not necessarily mean progress according to insurance companies. (For a full explanation of functional outcomes see Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists” by Diana L. Thompson or take a look at this book at Google Books) For more info on Soap Notes Google Book Online -Review for Massage National Certification
The Art of the Chart Documenting Massage Therapy with Massagenerd.com - Soap charts of all sorts
Please also check the
insurance billing manual updates and the
blog for more information.
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