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How Important is Documentation?
A colleague and I were discussing the importance of documenting massage sessions this morning, so I decided to throw the question out there: How important is documentation?
I can tell you that in my practice, it is extremely important; I have more than a dozen practitioners, and clients may be seen by more than one person. We also file insurance and get a lot of doctor and dentist referrals, and you simply cannot conduct that type of business unless you are willing to keep careful documentation.
On the other hand, I know a lot of lone practitioners who don’t think it’s a big deal at all. I think I’ve mentioned before that I was the administrator at a massage school when licensure came into our state, and there was a grandfather period for people who had documented at least 4 years of practice and 400 documented massages. I couldn’t believe the number of students who called the school to ask, “What do you mean, documented?” My reply was massage that SOAP notes and other pertinenet documents, such as doctor’s prescriptions or other medical information was in the client’s file. I was appalled at the number of people who said, “Oh, that’s all in my head.”
That is totally unprofessional, and in many places, illegal. Most states with a practice act require documentation of sessions, including a statement of informed consent, proof of a privacy notice having been provided, and SOAP notes.
An important thing to remember is that the client file, in many states, belongs to the client. They may walk in the door and request their file, and you are obligated to give it to them. Wouldn’t you feel silly if a client came in, announced that they were moving away and would like to have their file to give to their new therapist, and you had to say you didn’t do any record-keeping? I believe you would.
Keeping good documentation is one of the hallmarks of a professional. What would you think of your physician if he didn’t keep any notes? If you want to be thought of as a health care professional, you have to conduct your practice as one.
Peace & Prosperity,
Laura Allen
I can tell you that in my practice, it is extremely important; I have more than a dozen practitioners, and clients may be seen by more than one person. We also file insurance and get a lot of doctor and dentist referrals, and you simply cannot conduct that type of business unless you are willing to keep careful documentation.
On the other hand, I know a lot of lone practitioners who don’t think it’s a big deal at all. I think I’ve mentioned before that I was the administrator at a massage school when licensure came into our state, and there was a grandfather period for people who had documented at least 4 years of practice and 400 documented massages. I couldn’t believe the number of students who called the school to ask, “What do you mean, documented?” My reply was massage that SOAP notes and other pertinenet documents, such as doctor’s prescriptions or other medical information was in the client’s file. I was appalled at the number of people who said, “Oh, that’s all in my head.”
That is totally unprofessional, and in many places, illegal. Most states with a practice act require documentation of sessions, including a statement of informed consent, proof of a privacy notice having been provided, and SOAP notes.
An important thing to remember is that the client file, in many states, belongs to the client. They may walk in the door and request their file, and you are obligated to give it to them. Wouldn’t you feel silly if a client came in, announced that they were moving away and would like to have their file to give to their new therapist, and you had to say you didn’t do any record-keeping? I believe you would.
Keeping good documentation is one of the hallmarks of a professional. What would you think of your physician if he didn’t keep any notes? If you want to be thought of as a health care professional, you have to conduct your practice as one.
Peace & Prosperity,
Laura Allen
Views: 82
Comment
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Comment by Donna Whitton on August 18, 2009 at 10:06pm
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Although I'm a firm believer in keeping good documentation, I've yet to implement a privacy policy that I hand out: Any tips, suggestions, or even samples would be greatly appreciated so I could enforce this change immediately.
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Comment by Susan G. Salvo on August 16, 2009 at 9:09pm
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I now like APIE over SOAP.
With SOAP, it's
Subjective assessment, then
Objective assessment, then
Assessemnt again???
And finally
Plan.
No evaluation process in built with SOAP.
APIE is
Assessment (both subjective and objective elements),
Plan,
Implemetaion, and
Evaluation.
This format seems to be a much more comprehensive approach over SOAP.
And many healthcare professional are abandoning SOAP for better documenting practices.
For treatment planning, I love the PPALM format, which stands for
Purpose of session
Pain
Allergies and skin conditions
Lifestyle (of the client), and
Medical history and medications.
We teach this method as part of the client intake during student clinics.
Graduates come back years later and said how awesome this systematic data collection is for them in their practice.
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Comment by Robert Chute on August 16, 2009 at 8:11pm
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Interesting. I would have thought a note like HM might have helped the therapist's case.
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Comment by Lisa Santoro on August 15, 2009 at 3:26pm
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A quite accomplished colleague was unfortunately sued a few years back. Their work was incredible, they had a very loyal client base and excellent skills, but their note taking was not up to par. When the therapist was accused of acting inappropriately, their notes were subpoenaed for the case. The notes were not complete, there were comments about the client's personality ("HM" written to express "high maintenance") and not all areas worked were listed. The notes did not support the therapist's case, and actually prolonged some of the aspects of the investigation. Luckily for my colleague, the case eventually was dismissed. Had their notes been complete and in order, their situation could have been cleared up much more quickly.
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