SOAP Notes

Protect Your Practice

With Solid Documentation

Massage Magazine

Issue 145 June 2008

Why are SOAP notes important for all massage therapists? For one moment , allow yourself to consider what would happen to your practice in the even of a formal complaint or lawsuit. Under any circumstance, this would be devastating. Now imagine needing to defend your name and the services you provided that disgruntled client-with no form of dated written records. It would be difficult, if not impossible, to prove your innocense. Are you willing to take that chance with your career?

     SOAP is simply an acronym for Subjective Objective Assessment Plan. For those who are uncomfortable writing SOAP notes: Don't be. Here is a complete breakdown of what SOAP notes are and how you can adapt them to meet your specific needs.

     The easiest way to explain what is entailed in a properly written SOAP note is to think of it as a verbal photograph, or a photo that details who the client is that seeks your services and what brought him to you (his chief complaint). It should include information about his lifestyle and the specific condition he presents with, an outline of the techniques and modalities you used in treating the condition, information about the client's response to the session and the future goals of both parties.

     The note should be easily understood by other therapists, who may need to continue ar assist in the client's treatment. And for therapist practicing in the medical field, it must be medically accurate to allow other medical professionals and ancillary providers to make proper decisions reguarding the client's future care.

What's your excuse?

     Many massage therapists practicing in salons, spas, and private practices often keep very little to no record of the sessions they provide, and often believe SOAP notes are only for massage therapists working in the medical field.

     Then there are the therapists who were never trained to write SOAP notes. Many times these therapists are overwhelmed and unsure of exactly what to notate, or how; therefore, they often do nothing.

     Next are the massage therapist working in the medical field who believe that because they work in a medical facility (in the office of a physician, chiropractor or physical therapist for example), they are not required to maintain SOAP notes. For these therapists: This is not only wrong, it is unethical.

     Every massage therapist who sees "patients" (which is any client who is sent to you for treatment of a specific condition by a physcian) must keep detailed documentation of each and every session. Within the medical community, we are expected to maintain the same professional standard as allother ancillary providers. Think about it this way: You would not expect a nurse to administer medication to you without charting in your record what you were given and when it was given to you.

     There are also massage therapists who say they do not have time to document every session. To that I can only sugguest this: Make time.

Where SOAP comes from

     Many companies in the massage field offer SOAP charting software. YOu can also do as I have done , and design a form that fits your practice's specific needs. There is basic information that all SOAP notes should contain, but there is no manditory, standard form to which we must all conform.

     SOAP note forms can be made as simple or elaborate as you like. Some forms simply have boxes in which the therapist writes the information under each SOAP heading. Others have a check-off style, with compiles lists that contain the information that the therapist needs to collect.

     As the information is obtained, the area is either checked or filled out. As a result, massage therapist working in a physical therapy clinic may include range of motion and strength information, while another therapist working in an obstetrician's office might have an areas for gestational week and due date.

     Once you understand what belongs under each heading, all you have to do is fill in the information. Writing down a quick line or two about why the client came in for massage, what type of massage was given and how the client responded, along with the date, is all you really need.

Subjective Notes

     Numerous therapist report having the most difficulty writing subjective notes. Remember, subjective notes are simply a record of exactly ehat theclient says. Unfortunatley, most clients do not freely share all the information needed in regard to their conditions- not on purpose, of course. They simply either forget some of the symptoms they have experienced or assume the other things they are experiencing are not relative to their chief complaint(s).

     This is where the massage therapist becomes a detective, asking questions that assist the client in expressing more of what she is experiencing. It is very similar to a reporter conducting an interview or collecting as much information as possible to report an accurate story.

     Every subjective note should include key points of information concerning the client's lifestyle and the condition she presents with. General information about her job, daily activities, and even hobbies can sometimes give the therapist clues that can be used to help address the client.

     Other pieces of information that can be useful include any past accidents, surgeries and childhood illnesses. Do not forget to cover any current health issues, such as diabetes, hypertension, arthtitis etc..

     Next the therapist needs to collect information specific to the clients chief complaint (why she is seeking massage). This information should include:

• Location: where she is experiencing the symptoms
• Onset: how and when the condition began
• Frequency: how often she experiences the condition
• Quality: is the pain sharp, dull, tingly or numb
• Severity: the client classifies her condition  as mild, moderate or severe
• Duration: how long the pain normally lasts
• Radiating Patterns: does she expereince symptoms in areas other than the location of the intial complaint
• Aggravating Factors: what aggravates the condition
• Relieving Factors: what improves the condition
• Night Pain: is the condition better or worse at night
• Prior Treatments: what has she tried in the past and the results
• History of Region: any past injuries to area
• Diagnostic Studies: x-rays, computed tomography (CT) scan, electromyogram (EMG), or magnetic resonance imagine (MRI) in conjunction with the condition
• Medication: prescribed and over-the-counter medications she is currently taking

     One reason the interview process is so important is it allows the massage therapist a greater opportunity to insure the client does not have any contrindications for treatment. Performing a complete interview also shows a heightened level of professionalism and concern for the cleint/patient's well being.

Objective Notes: What you see and feel

     The majority of massage therapists have no problem when it comes to writing objective notes. Objective notes are just what we see and feel throughout the session.

     As massage therapists, we make visual assessments of our clients the moment we first see them. Information from visual assessment should be noted, especially in the event of postural deviations, gait irregularities, balance issues: the fluidity (or lack) of movement, scars, bruises or other skin abnormalities.

     For the massage therapist practicing in the medical field and addressing musculoskeletal dysfunctions, objective notes should include an active range of motion evaluation-especially in the intial visit, at re-evaluation visits and at the patient's last visit. This is important because both the physicians and the insurance companies need tangible proof the therapy being applied is improving the patient's condition. Tangible proof often requires a notable improvement in range of motion with the decrease in pain.

    For the therapist in the medical field, the objective note should include any diagnostic tests you may have performed and the results of those tests. An example would be if the therapist performed an alar ligament test to check spinal cord mobility on a client complaining of cervical pain.

     The last part of the objective note is the data collected as the therapist palpates tissues during the session. Here is where you document muscle tone, muscle strength and balance as well as any spasms. You should also notate adhesions and trigger points.

Assessment Notes

     There are three important elements kept in the assessment note:

1. Why your services were needed

     First comes the statement as to why the cleint sought treatment. For therapists working in a salon type setting this can ne a small statement that covers the client's chief complaint as stated during the interview process. For the therapist working in the medical field, this is the diagnosis given to you by the referring physician; include the physician's name here.

2. What techniques and modalities were used, and what was achieved.

     The second part contains a list of techniques and modalities used during the session, combined with a statement of the client's expereince. Note whether or not the client received pain relief. . Was there an increase in range of motion? Did trigger points release or spasms stop?

3. What the future goals are and how achievable they are

     Finally, the therapist's opinion of the cleint's response to the session is documented. Is the cleint progressing as expected? Are treatment goals achievable? Does the cleint need to be re-evaluated by the referring physician?

     This is also whre I suggest a therapist note any unusual or inappropriate behavior displayed by the client. This includes any disturbing comments, inappropriate touching (or attempt of the same nature) or any attempts by the client to expose him/herself-even if there is an accidental exposure caused by insufficient draping.

     Again, keep in mind you must document everything, even if you are the person who made the mistake. Again, what if there was a complaint? Documenting any inappropriate behavior could save your reputation and your practice.

Plan Notes

     The plan section of the SOAP note is an outline of how the massage therapist intends to address the client during future visits, and a listing of the techniques that will be used. (Massage techniques in the medical field are defined as the different types of massage strokes, or massage styles performed, such as myofascial release, neuromuscular therapy, neuromuscular re-education, therapeutic exercise, joint capsule release and lymaphatic massage.)

     Here, also include any modalities you may utilize. (Modalities in the medical field are considered to be the aids a therapist uses to assist or enhance a session, such as hot or cold packs, and resistance bands.) The last element of the plan note is a statement as to the frequency and duration of sessions.

What is your career worth?

     There is no doubt a significant amount of information is maintained within a SOAP note. Yet, with a form designed to meet your needs and a little practice, most notes can be written in just a few minutes, Isn't the future of your career worth a few minutes?

7 SOAP NOTE TIPS

1. Sign and date every SOAP note

2. Complete SOAP notes immediately following each session

3. Use a writing style, aterminology and abbreviations appropriate to the setting in which you practice

4. Make certain your notes are neat, complete and can be clearly understood by others who may need to review the information

5. Only physicians have the ability to diagnose conditions and injuries. In the even that you feel a physician may have missed a diagnosis, the best course of action is to contact the physician's office and share your findings or concerns (without diagnosing). Then ask if she would like to see her patient or order some further diagnostic testing.

6. Observe all confidentiality laws that govern your practice

7. Stay within your scope of practice, and only perform techniques for which you are properly trained.