SOAP Charting for Massage Therapists
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
CARE Notes By Mary Kathleen Rose
Massagenerd.com - Soap charts of all sorts
