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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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Permalink Reply by Beulah on October 19, 2009 at 8:26am

Hi Donna ,
I personally obtain signatures from clients when I change there plan for consent purposes . With the amount of people who get caught up in legal issues these days" he says she says " It is just better for you as a professional to make sure all the paperwork is covered . That way if a relaxation massage turns into a therapeutic for a particular issue it is documented , and if you end up referring your client to another professional you have notes to give the client to pass on unless you have signed consent to do so of course. I have my clients update there paperwork the first visit of the new year so everything is current although I do encourage my clients to update periodically if needed .(Mainly my medical patients that are having other treatments alongside massage and bodywork )
As far as my soap notes it is an ongoing thing trying to find a style that suites me with the range of techniques I do . I have 4 different ones right now . One for Relaxation Massage , one for therapeutic ,one for reflexology and the other for everything else . One day I will find one that suites all hopefully .
Have a great day .

Donna Whitton said:

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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Permalink Reply by Trevor Chisman on October 23, 2009 at 5:49am

Hi everyone.

I use SOAP notes because it was how I was taught and also because in one of my guises I work as a deep tissue therapist for a local Physio business, they use SOAP and I would just confuse myself if I was using different note taking formulas on subsequent days. However as a massage therapist I see that SOAP notes aren't perfect by any stretch of the imagination.

I do however take signatures, both on the first visit to agree the treatment plan and then on subsequent visits only if the medical history or treatment plan changes. I would require a signature even for a Swedish massage as this is the planned treatment and everyone has agreed that is what will be happening.

Also if I haven't seen a client for over 6 months I do a new intake form just to be sure I know of any changes, people often forget that they have started taking a new medication since they last saw you if it has been some time since both occurred.

I always keep notes in paper format but haven't ruled out starting to use a computer for this, it would be great to hear from people who do keep notes on a computer and how easy they find this.

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Permalink Reply by Angela Diane Bishop on October 23, 2009 at 9:05am

Subject of discussion: Intake forms, SOAP, PPALM, APIE, Informed Consent, etc.
Susan, are these forms available somewhere in a word document format to be saved to my computer, typed on and printed off, etc.?

Thanks, Angie PS: I am a new therapist in AR (Waiting for license and setting up business plan, etc.)

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Permalink Reply by Susan G. Salvo on October 23, 2009 at 9:35am

I just created a pdf of the form and uploaded it to our school website. Ck it out.

http://www.lamassageschool.com/downloadforms/PPALM%20Treatment%20Pl...

These forms are also available through the online resources for my books Massage Therapy: Principles and Practice as well as Mosby’s Pathology for Massage Therapists.

Be on the lookout for Massage Online by Elsevier. These courses will have a forms tab where you can download this and other important forms for your practice on demand.

I hope this helps.

Good luck with your new career.

Angela Diane Bishop said:

Subject of discussion: Intake forms, SOAP, PPALM, APIE, Informed Consent, etc.
Susan, are these forms available somewhere in a word document format to be saved to my computer, typed on and printed off, etc.?

Thanks, Angie PS: I am a new therapist in AR (Waiting for license and setting up business plan, etc.)

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Permalink Reply by Angela Diane Bishop on October 23, 2009 at 9:55am

Will check these out. What about samples for marketing - flyers, discounts, coupons, business cards, etc.?

Thanks so much, Angie

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Permalink Reply by Susan G. Salvo on October 23, 2009 at 10:01am

Contact the ABMP for this one. They have lots of resources.

Angela Diane Bishop said:

Will check these out. What about samples for marketing - flyers, discounts, coupons, business cards, etc.?

Thanks so much, Angie

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Permalink Reply by Andrea McCully on December 20, 2009 at 9:50pm

This was VERY helpful.. Thank you Susan!

Susan G. Salvo said:

I just created a pdf of the form and uploaded it to our school website. Ck it out.

http://www.lamassageschool.com/downloadforms/PPALM%20Treatment%20Pl...

These forms are also available through the online resources for my books Massage Therapy: Principles and Practice as well as Mosby’s Pathology for Massage Therapists.

Be on the lookout for Massage Online by Elsevier. These courses will have a forms tab where you can download this and other important forms for your practice on demand.

I hope this helps.

Good luck with your new career.

Angela Diane Bishop said:
Subject of discussion: Intake forms, SOAP, PPALM, APIE, Informed Consent, etc.
Susan, are these forms available somewhere in a word document format to be saved to my computer, typed on and printed off, etc.?

Thanks, Angie PS: I am a new therapist in AR (Waiting for license and setting up business plan, etc.)

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Permalink Reply by Susan G. Salvo on December 21, 2009 at 10:19am

Here ya go.

Let me know if you need anything else.

And Happy Holidays!!

Andrea Rose said:

This was VERY helpful.. Thank you Susan!

Susan G. Salvo said:
I just created a pdf of the form and uploaded it to our school website. Ck it out.

http://www.lamassageschool.com/downloadforms/PPALM%20Treatment%20Pl...

These forms are also available through the online resources for my books Massage Therapy: Principles and Practice as well as Mosby’s Pathology for Massage Therapists.

Be on the lookout for Massage Online by Elsevier. These courses will have a forms tab where you can download this and other important forms for your practice on demand.

I hope this helps.

Good luck with your new career.

Angela Diane Bishop said:
Subject of discussion: Intake forms, SOAP, PPALM, APIE, Informed Consent, etc.
Susan, are these forms available somewhere in a word document format to be saved to my computer, typed on and printed off, etc.?

Thanks, Angie PS: I am a new therapist in AR (Waiting for license and setting up business plan, etc.)

Attachments:

Treatment Plan.doc, 35 KB

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Permalink Reply by I. Paul Dunsdon on December 21, 2009 at 11:48am

I use the SOAPnotes format on all my clients for a number of reasons. The most important one is CYA (cover your ass). Its he-said-she-said in the privacy of my office so I document as much as I can to protect myself. The second is to show progress and value of service to the client. If there is ever any question as to the effectiveness of the treatments I can show them their progress.
From a marketing stand point, I keep a short record about their personal lives. Like recent events and celebrations that are shared with me. This helps to build repore, and in this game its the little things that make all the difference in client loyalty.

As far as format... Its K.I.S.S.
A simple excel program with date and time of visit. I keep a password protected copy on my smart phone and a hard copy in a locked file.

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Permalink Reply by Marlene Mayman on November 12, 2013 at 2:43pm

Beulah said:

If anyone has any formats they can send me that I can try I would really appreciate it.

Hard to find info online about APIE or APIER formats, but I did find this:

http://www.uncp.edu/nursing/lec/CH15.pdf

See page 255-6 or see the attached files, which include screen captures of the two pages of relevant info. Hope this helps.