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What type of Soap Note format do you use ?
Hi everyone , I have been back and forth over the past few years trying to find a Soap note format that I like and would like suggestions , paper , computer What type do you like ?
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Replies to This Discussion
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Permalink Reply by Susan G. Salvo on
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Ilike APIE (assessment, plan, implementation, evaluation) for record keeping.
But I use PPALM for treatment planning (purpose of session, pain, allergies and skin conditions, lifestyle, and medical history/medications).
Yes, APIE and PPALM serve different purposes for me - PPALM helps me gather all the information I need to formulate a client-centered plan of care.
Some people like CARE notes.
I had a hard time making SOAP work for me.
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Permalink Reply by Beulah on
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I keep trying Soap but maybe I will try the others because after all this time and they aren't working for me either thank you for your response I appreciate it
Susan G. Salvo said:Ilike APIE (assessment, plan, implementation, evaluation) for record keeping.
But I use PPALM for treatment planning (purpose of session, pain, allergies and skin conditions, lifestyle, and medical history/medications).
Yes, APIE and PPALM serve different purposes for me - PPALM helps me gather all the information I need to formulate a client-centered plan of care.
Some people like CARE notes.
I had a hard time making SOAP work for me.
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I think you are echoing what many, if not most, MTs feel.
SOAP wasn't designed for us - and still we try to adapt to it, which leads to the frustration you feel.
I quit using SOAP long ago and have never regretted it.
Beulah said:I keep trying Soap but maybe I will try the others because after all this time and they aren't working for me either thank you for your response I appreciate it
Susan G. Salvo said:Ilike APIE (assessment, plan, implementation, evaluation) for record keeping.
But I use PPALM for treatment planning (purpose of session, pain, allergies and skin conditions, lifestyle, and medical history/medications).
Yes, APIE and PPALM serve different purposes for me - PPALM helps me gather all the information I need to formulate a client-centered plan of care.
Some people like CARE notes.
I had a hard time making SOAP work for me.
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If anyone has any formats they can send me that I can try I would really appreciate it.
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Permalink Reply by Donna Whitton on
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I still use SOAP because that's what I was taught in school. I would, however, like to find something a little more massage oriented.
For APIE, what exactly do you write for the assesment? what they complain about?
and what's does CARE stand for?
Any suggestions, links, or examples would be greatly appreciated?
Susan G. Salvo said:Ilike APIE (assessment, plan, implementation, evaluation) for record keeping.
But I use PPALM for treatment planning (purpose of session, pain, allergies and skin conditions, lifestyle, and medical history/medications).
Yes, APIE and PPALM serve different purposes for me - PPALM helps me gather all the information I need to formulate a client-centered plan of care.
Some people like CARE notes.
I had a hard time making SOAP work for me.
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Permalink Reply by Andrea McCully on
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I have been using WinCity SOAPnotes for the PC, but I am kind of having a hard time with it. I hate the assessment portion of it. I thought about getting MassageOfficePro but heard that they didn't stand behind their product, so I really don't know what to do. I prefer computer/printer as opposed to manually writing them out.
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Permalink Reply by Gerry Bunnell on
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I also use SOAP notes on Chiropractic software (what is available in the chiro clinic I work in) avoiding the Assessment section. Doing assessment avoiding treading on the grounds of diagnosing can be tricking and tedious. I never considered using another format being unaware that there ARE other formats. Thanks for bringing up this subject Beulah.
Andrea Rose said:I have been using WinCity SOAPnotes for the PC, but I am kind of having a hard time with it. I hate the assessment portion of it. I thought about getting MassageOfficePro but heard that they didn't stand behind their product, so I really don't know what to do. I prefer computer/printer as opposed to manually writing them out.
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What is the importance of SOAP?
To formulate and document a client’s treatment plan, right?
Doesn’t S, O, and A lead to P?
We already have clients fill out an intake form, right?
Okay, when a client hands it back to you, go over the data on the form.
If the intake form is confined to a single page (recommended), flip the form over and write P, P, A, L, M down the page (some forms have this provided).
Ask the client questions related to these assessment domains.
Oh yeah, the domains.
Purpose of session – What does the client want? Pain reduction? Stress reduction. You gotta ask.
Pain – If so, get specific.
Allergies and skin conditions – Is your client allergic to ingredients in your massage lubricant? Any skin rashes or skin conditions? You gotta ask.
Lifestyle – Is your client healthy? Does he or she get regular massages? Stress level? If your client is inactive, has never had a massage, and wants NMT, you will approach him or her differently than if your client is very active, has weekly massages, and want NMT.
Medical history and med use – Even with health conditions identified on an intake form, you need to ask questions about current S/S, stages of diease, how it’s managed, and complications, and med side effects what impact the massage, etc.
After your verbal consultation, you should be able to formulate a treatment plan.
Write it down.
Share it with your client.
Make modifications based on your client’s input.
Obtain your client’s signature.
Now, head for the massage room.
Back to my SOAP box (he he), why bother separating subjective from objective data? It never made sense to me.
PPALM (pronounced P-PALM, a two-syllable word), works beautifully for MTs.
I hope this helps.
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Do you do this for every client, even when they are a loyal, repeat customer who comes for a simple, Swedish massage simply to relax? You have them sign every time? If so, any suggestions on how to make this change fluidly in my practice since I don't have them sign 'in' before each massage. And, what should I do with a client who can't sign?
As for your treatment plan, do you explaind the use of trigger point, friction, stripping, use of heat and where/on what muscles?
I do like the explaination for the use of PPALM and would like to make the change so suggestions would be appreciated.
Susan G. Salvo said:What is the importance of SOAP?
To formulate and document a client’s treatment plan, right?
Doesn’t S, O, and A lead to P?
We already have clients fill out an intake form, right?
Okay, when a client hands it back to you, go over the data on the form.
If the intake form is confined to a single page (recommended), flip the form over and write P, P, A, L, M down the page (some forms have this provided).
Ask the client questions related to these assessment domains.
Oh yeah, the domains.
Purpose of session – What does the client want? Pain reduction? Stress reduction. You gotta ask.
Pain – If so, get specific.
Allergies and skin conditions – Is your client allergic to ingredients in your massage lubricant? Any skin rashes or skin conditions? You gotta ask.
Lifestyle – Is your client healthy? Does he or she get regular massages? Stress level? If your client is inactive, has never had a massage, and wants NMT, you will approach him or her differently than if your client is very active, has weekly massages, and want NMT.
Medical history and med use – Even with health conditions identified on an intake form, you need to ask questions about current S/S, stages of diease, how it’s managed, and complications, and med side effects what impact the massage, etc.
After your verbal consultation, you should be able to formulate a treatment plan.
Write it down.
Share it with your client.
Make modifications based on your client’s input.
Obtain your client’s signature.
Now, head for the massage room.
Back to my SOAP box (he he), why bother separating subjective from objective data? It never made sense to me.
PPALM (pronounced P-PALM, a two-syllable word), works beautifully for MTs.
I hope this helps.
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Great questions.
For most subsequent sessions, I repeat the prior treatment plan, especially if it serves the clinet's needs (i.e., relaxation, reduction of right shoulder pain, etc).
I also keep a date log on their PPALM (remember, this is usually the back of their intake form).
Example:
Donna Whitton: 8/3/09, 8/10/09, 8/24/09
You can record these dates of your regular clients to fit your needs (weekly, biweekly, monthly).
If there is a change in your client’s health or goals, the treatment plan is then modified and his or signature is obtained.
If a client cannot (or is unwilling) sign the plan, indicate than under “client signature.” Include the date it was recorded.
Yes, treatment plans includes areas you focused on, avoided, special techniques, and adjunctive modalities.
Try it. Let me know how it works for you.
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What do you do regarding patients who come regularly with just wanted a massage to relax? And why do you obtain their signature when you change the treatment plan?
The more I think about it, though, I'm planning on changing my forms; it's just a matter of taking the time to do so. I was also thinking about having my clients fill a new intake form at the beginning of the year just so I have a more up-to-date med. h/o.
Susan G. Salvo said:Great questions.
For most subsequent sessions, I repeat the prior treatment plan, especially if it serves the clinet's needs (i.e., relaxation, reduction of right shoulder pain, etc).
I also keep a date log on their PPALM (remember, this is usually the back of their intake form).
Example:
Donna Whitton: 8/3/09, 8/10/09, 8/24/09
You can record these dates of your regular clients to fit your needs (weekly, biweekly, monthly).
If there is a change in your client’s health or goals, the treatment plan is then modified and his or signature is obtained.
If a client cannot (or is unwilling) sign the plan, indicate than under “client signature.” Include the date it was recorded.
Yes, treatment plans includes areas you focused on, avoided, special techniques, and adjunctive modalities.
Try it. Let me know how it works for you.
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Hey Donna,
I re-obtain a client signature on the treatment plan only when there is a change to the plan.
But most clients want you to basically repeat what was done during the prior visit, so the plan is essentially repeated with no documentable changes.
I like your idea of annual client updates.
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