massage and bodywork professionals

a community of practitioners

How many therapists REALLY write out notes?

I'm curious to know how many therapists really write out SOAP notes for their clients.  If you do take notes, how do you go about crafting a plan for your clients - is it even worth your time if you're not sure the client is going to come back?

 

I run a website MassageCRM with the goal of making it easy to record SOAP notes, but I also aim to make it effective to do so.  I wonder if some therapists don't take notes or don't go back and refer to them later - and if so, I'd like to know why.

Views: 4621

▶ Reply to This

Replies to This Discussion

Permalink Reply by Lee Edelberg on March 10, 2012 at 9:41am

I spend a couple of minutes writing notes by hand on a form I created.  It's not in SOAP format. I write enough so I can remember next time who the individual is and what I found. Anything memorable gets noted.  Once I get to know a client well through repeated visits, I stop taking notes, unless there is something significantly different.

I'm self-employed and I schedule my sessions with enough time in between to take care of these things. I wouldn't actually want to do it on a computer. This would add another layer of complication i.e. having to have a computer available in my studio, having to deal with software, upgrades, backing up files, etc.

To me in a small private practice it doesn't seem worth it.

Permalink Reply by Lee Edelberg on March 10, 2012 at 9:49am

I don't mean to come across negatively, Jason.  I see potentially great value for your product in other situations.  A studio or practice that has multiple MT's for example, or someone who does a lot of medically-oriented massage that requires good record-keeping.  It could be a real boon. 

Permalink Reply by Therese Schwartz on March 10, 2012 at 11:18am

Hi Barbara!  I do the same thing!  Like you, my notes are better quality when I write them right away.  I'm much more confident in what I felt in the tissues.  When I can't remember, I write enough notes that I at least know what modalities I used so I can track what works for each person.

Barbara Helynn Heard said:

Aloha Therese,  I dont' always get my notes done right away.  But my notes are better quality when I do.  Once in a while I write "waited too long to write notes" in the observation section.  I am however disciplined always write at least skeletal notes so that I have a record of when I saw clients, and I write specific notes I'm satisfied with most of the time - maybe 90%

 

Aloha,

Barbara helynn

Permalink Reply by Jason Huie on March 10, 2012 at 5:00pm

Lee,

  I totally understand what you mean about adding complexity with taking notes after each session - and I can see what you mean about not wanting the extra clutter of a computer in your studio.  Taking notes might not fit for every massage therapist out there for a bunch of different reasons, but I believe that there is a benefit in recording notes for every massage therapist out there.  The I realized a funny thing when I read your notes - I think that new clients benefit more from your notes than your regulars.  I thought about what you said all morning, and I realized that it's totally possible to give an excellent quality of care to your returning clients because you know exactly what they like and need.  However, the tricky part is giving that same quality of care to your first and second time clients.  That is where I think keeping notes and plans benefits the most.  In any industry, keeping your clients and building that "regulars" genre is the most difficult because it requires that the customer feel that they somehow "need" to keep coming to you.  That need is generated by the idea that you have a plan for the client and that only you can fulfill that plan.  That is where I think the real value of notes comes into play - it allows you to establish that level of trust and need with your clients earlier and ensures that the client is getting the most out of every session.

Lee Edelberg said:

I don't mean to come across negatively, Jason.  I see potentially great value for your product in other situations.  A studio or practice that has multiple MT's for example, or someone who does a lot of medically-oriented massage that requires good record-keeping.  It could be a real boon. 

Permalink Reply by Lee Edelberg on March 10, 2012 at 5:18pm

Hi Jason,

So you're suggesting that if I have a longer-term plan for a client then they might be more likely to stay? 

That's a pretty interesting idea........I will give it some thought!

Permalink Reply by Therese Schwartz on March 10, 2012 at 9:14pm

The notes I take are really helpful, as Jason suggests, in figuring out what clients like and don't like, what works and what doesn't work.  That way they get sessions that are tailored specifically for them.  I tell everyone that there is a process of experimenting to see what will be the best course of action.  Documenting that definitely helps me!  I can't remember from one session to the next what I did with people.  Until a year ago I kept all that in my head but not so much any more! 

Permalink Reply by Marlene Mayman on October 23, 2013 at 2:49pm

I didn't keep very good notes in my initial private practice, but when I worked for a massage studio (where clients were sometimes shared or had significant health issues that required tracking) I got in the habit of keeping notes. I was struck by how helpful they were when seeing a client again, and since my focus now tends to be more towards the medical side of massage (I've studied orthopedic massage) they are critical to pursuing a more effective treatment plan.

I just read this blog article, "How Important is Documentation," and it's solidified my resolve to continue to keep good notes in the new practice I am about to open. I recommend everyone read it, there can be legal consequences for NOT keeping notes! http://www.massageprofessionals.com/profiles/blogs/how-important-is...

I am considering new formats over the traditional SOAP notes I was taught to take in school. I'm thinking about going with APIE/APIER or SOAPIER (probably APIER, since it's more compact).

APIE/APIER:

Assessment: Strengths and needs of individual clients identified through a Bradford Woods assessment
Plan: Written treatment plan designed to address the assessed individual needs
Implementation: Use of therapeutic activities to address goals
Evaluation: Written documentation evaluating individual goals at the conclusion of each session and at the end of the overall program
Revision: Reflects care plan modifications suggested by the evaluation. Changes may be made in desired outcomes, interventions or target dates.

SOAPIER:

s (subjective data) - chief complaint or other information the patient or family members tell you.
o (objective data) - factual, measurable data, such as observable signs and symptoms, vital signs, or test values.
a (assessment data) - conclusions based on subjective and objective data and formulated as patient problems or nursing diagnoses.
p (plan) - strategy for relieving the patient's problems, including short- and long-term actions.
i (interventions) - measures you've taken to achieve expected outcomes.
e (evaluation) - analysis of the effectiveness of your interventions.
r (revision) - changes from the original care plan

An example for SOAPIER: http://www.scribd.com/doc/80457556/SOAPIER-Note-Charting-Examples-S...

Regarding things that would make note taking easier, having body charts of the anterior, both sides and posterior that can be easily marked has been really helpful to me in jotting down quick notes when there wasn't much time between clients. Shortcuts to note various client preferences can also be very helpful, such as depth of pressure preferred (not as stated by the client but what they were actually comfortable receiving), table height adjustments, special bolstering or positioning needs, temperature preferences (e.g., table really hot or no heat at all) ... all are useful to see at a glance. In an office with multiple MTs seeing the same client, a key for abbreviations can be helpful (BL = bilateral, FBM =  full body massage, and so forth).

Permalink Reply by Gordon J. Wallis on October 24, 2013 at 11:33am

I have no time to take notes. But I dont need too.  Any client that is coming to see me because of pain. I go through the entire body eliminating or down grading any tender or painful spots on the body. If the client feels at least 50% better after the session, they reschedule and come back within a week for a follow up. They give me a report on how they are doing. Then I do the same thing. Usually after a couple sessions they begin feeling much better. And each session there are less and les tender or painful spots.  Or they can lift their arm higher before it hurts. Whatever their problem may be.  Usually I get them back to function within four to seven sessions. And I can often tell if Im going to be effective for their problem within two sessions. I dont rip anyone off with never ending treatment plans when there is no clinical improvement after two or three sessions.  I dont dont bill insurance companies. So do not need to dcument anyway.

Permalink Reply by Therese Schwartz on October 24, 2013 at 11:56am

I was the first person to respond on this thread, back in March.  I recently quit taking notes.  It was one more thing that I was stressing about, and because I treat each person where they are on any given day it became less relevant to document what had happened before.  I'm much happier since I don't have the stress of keeping up with notes.  Like Gordon, I don't do insurance billing.  For a few clients I do Flex Pay but all I have to do is send them a receipt with a few comments on what I did in the session.

I can see how notes would be really handy in a situation like Marlene's with multiple therapists.  I work by myself so I don't have that concern.

Permalink Reply by Marlene Mayman on October 25, 2013 at 10:33am

Before you completely write off note-taking (ha ha), do read and consider the article I linked to:
http://www.massageprofessionals.com/profiles/blogs/how-important-is...

Permalink Reply by Gordon J. Wallis on October 26, 2013 at 11:18am

For me personally. I just dont need treatment notes. Now if you job requires it, thats different.  But I had a client the other day that had maybe fifty triggerpoints. I worked on her for 80 minutes. Her initial complaint was neck pain that radiated to the midd back. I combed her whole body for trigger points. After the session her presenting symptoms were gone. Thats all I care about. She was way happy. I cant imagine documenting all that? I told her if she feels the slightest hint of that pain coming back to come in and see me again. It was created from a one time event. Lifting heavy boxes while moving.   And if she did come back. I wouldnt need treatment notes to help her. Im not saying treatment notes are wrong. I don't know? But for some reason. I dont need em?

Permalink Reply by Therese Schwartz on October 26, 2013 at 1:55pm

I don't think it's required by the state for me.  I found that I used the notes so rarely that it was just another task to complete every day when I'm already feeling overwhelmed.  I appreciate everyone's perspective on this.  If I find that I need notes in the future, I will find a better way than hand writing them like I was.

▶ Reply to Discussion

RSS

© 2024   Created by ABMP.   Powered by

Badges  |  Report an Issue  |  Terms of Service

Sign in to chat!