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Soap Notes
So the question is how many LMT's actually use soap notes in there personal practice (not employees).....Do you use soap notes for every client that walks in your door? Or do you only do notes on the clients that have a medical issue, or a sports injury and skip the notes on the ones that are just there for fluff and buff? Let the chatter begin and let me know where you stand on this.
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Replies to This Discussion
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Permalink Reply by Susan G. Salvo on
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Hey Bianca,
Ck out this older forum on soap. I most likely will answer a lot of your questions.
http://www.massageprofessionals.com/forum/topics/what-type-of-soap-...
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Permalink Reply by Darcy Neibaur on
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I do notes on every client I work on whether they come to me or I go to them as an outcall. Also those who come back on a regular basis have to fill out a new mini soap note in case of changes in their medical health. Here in FL it is the law.
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Permalink Reply by Bianca Berrios on
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Thanks Susan! Very helpful :)
Susan G. Salvo said:Hey Bianca,
Ck out this older forum on soap. I most likely will answer a lot of your questions.
http://www.massageprofessionals.com/forum/topics/what-type-of-soap-...
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Bianca, I love the fact that these discussions are taking place. Thank you.
We discuss (and debate) the usefulness (or lack thereof) of soap all the time in class.
It is from these wonderful discussions that PPALM was born.
PPALM's assessment domains address what we need to know to devise a treatment plan for clients.
Bianca Berrios said:Thanks Susan! Very helpful :)
Susan G. Salvo said:Hey Bianca,
Ck out this older forum on soap. I most likely will answer a lot of your questions.
http://www.massageprofessionals.com/forum/topics/what-type-of-soap-...
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Permalink Reply by Laura Allen on
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Absolutely. I don't care if they want fluff and buff, every therapist in my place including me writes SOAP notes on every session. Since we file a lot of insurance I expect my therapists to go above and beyond in the quality of their notes, and I also teach a class on Intake Protocols and SOAP Charting for Medical Massage.
I have a therapist who works for me that came from a chiropractor's office and she told me they didn't keep any SOAP notes there. How appalling.
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Bianca,
Just remember that SOAP is just one method of documenting client sessions. There are several ones out there (APIE, CARE, PPALM, etc).
If you look at the history of SOAP, it has evolved to SOAPIER (subjective, objective, assessment, plan, implementation, evaluation, and review) to fill the holes SOAP leaves us.
One criticism for SOAP is that this format lacks flexibility (which is kind of what you stated earlier) and not practical for clients who do not have complaints and just wants to relax).
There is also no consistency of what “A” or “P” stands for or what information is placed in the “A” or the “P” sections of the format. For example, “A” could mean assessment, activity, or even analysis; “P” might mean procedure (past or present tense) or planning (future tense). For this reason, always include a legend somewhere on the document.
Whatever format you decide, documentation of your client’s complaint, condition, and treatment plan must be consistent, concise, and comprehensive.
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Permalink Reply by Marissa on
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I have to say that I have always used the SOAP format. Personally, I have never had any issues with filling them out. I fill out notes for every client as an IC for a PT company as well as in private practice. I think it stems from the fear that in school we were informed that you will most likely be sued at least one time in your career.
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Wow Marissa,
You made a very profound statement.
When working on the third edition of my textbook, Massage Therapy: Principles and Practice, I found most therapists were taught SOAP but, over time, stopped using them. Rather than criticize these therapists, I wanted to dive deeper into the issue and understand why. Most reasons boiled down to what they perceived as a lack of usefulness in their practice.
When I came across a therapist who did use SOAP, it was usually because the state or their employer required them and they did not know any other method of client documentation.
This is interesting.
If what we are teaching students/therapists is not withstanding the test of time, something’s wrong (and it probably not the therapists).
So I began to ask therapists what they needed to know to provide safe targeted client-centered sessions. What they told me time and time again was:
1) What did the client want (purpose or P)
2) Does the client have any pain (pain or second P)
3) Does the client have any allergies to topical agents or skin rashes (allergies or skin conditions: A)
4) A little about the client’s lifestyle such as occupation, level of physical activity, level of stress, and past massage experience (lifestyle or L)
5) Medical history which includes use of meds for disease management (medical history or M)
After gathering info on these assessment domains (PPALM) from the client intake form or client interview, the therapist can now formulate a client-centered treatment plan.
I’m working on the fourth edition now.
Your opinions will influence the chapter on client documentation.
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Susan- I didn't mean to ruffle any feathers. Personally, I think the PPALM format is fantastic. Perhaps if I had learned that format initially, I would have adapted and still been using it today instead. I also think that working day in and out with Physical Therapists has something to do with my sticking w/ SOAP. That is what they are familiar with and when you go back and forth treating their patients and then referring your clients to them, it's best to stick with something familiar with both parties. Plus using SOAP notes coincides with having a detailed medical intake form. All things listed in PPALM are in my intake form. I then go over the intake form with the client. A lot of times, the clients mention things they did not state on the intake. Then, with direct questioning for notes, it is again semi-duplicated. I diligently practice the CYA method. Hand in hand, I have no complaints and no reason to change. Unless, of course, PPALM, APIE, or CARE become the industry standard.
Susan G. Salvo said:Wow Marissa,
You made a very profound statement.
When working on the third edition of my textbook, Massage Therapy: Principles and Practice, I found most therapists were taught SOAP but, over time, stopped using them. Rather than criticize these therapists, I wanted to dive deeper into the issue and understand why. Most reasons boiled down to what they perceived as a lack of usefulness in their practice.
When I came across a therapist who did use SOAP, it was usually because the state or their employer required them and they did not know any other method of client documentation.
This is interesting.
If what we are teaching students/therapists is not withstanding the test of time, something’s wrong (and it probably not the therapists).
So I began to ask therapists what they needed to know to provide safe targeted client-centered sessions. What they told me time and time again was:
1) What did the client want (purpose or P)
2) Does the client have any pain (pain or second P)
3) Does the client have any allergies to topical agents or skin rashes (allergies or skin conditions: A)
4) A little about the client’s lifestyle such as occupation, level of physical activity, level of stress, and past massage experience (lifestyle or L)
5) Medical history which includes use of meds for disease management (medical history or M)
After gathering info on these assessment domains (PPALM) from the client intake form or client interview, the therapist can now formulate a client-centered treatment plan.
I’m working on the fourth edition now.
Your opinions will influence the chapter on client documentation.
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Marissa, no feathers ruffled here.
I agree with and appreciate your candidness.
Marissa Macias said:Susan- I didn't mean to ruffle any feathers. Personally, I think the PPALM format is fantastic. Perhaps if I had learned that format initially, I would have adapted and still been using it today instead. I also think that working day in and out with Physical Therapists has something to do with my sticking w/ SOAP. That is what they are familiar with and when you go back and forth treating their patients and then referring your clients to them, it's best to stick with something familiar with both parties.
Susan G. Salvo said:Wow Marissa,
You made a very profound statement.
When working on the third edition of my textbook, Massage Therapy: Principles and Practice, I found most therapists were taught SOAP but, over time, stopped using them. Rather than criticize these therapists, I wanted to dive deeper into the issue and understand why. Most reasons boiled down to what they perceived as a lack of usefulness in their practice.
When I came across a therapist who did use SOAP, it was usually because the state or their employer required them and they did not know any other method of client documentation.
This is interesting.
If what we are teaching students/therapists is not withstanding the test of time, something’s wrong (and it probably not the therapists).
So I began to ask therapists what they needed to know to provide safe targeted client-centered sessions. What they told me time and time again was:
1) What did the client want (purpose or P)
2) Does the client have any pain (pain or second P)
3) Does the client have any allergies to topical agents or skin rashes (allergies or skin conditions: A)
4) A little about the client’s lifestyle such as occupation, level of physical activity, level of stress, and past massage experience (lifestyle or L)
5) Medical history which includes use of meds for disease management (medical history or M)
After gathering info on these assessment domains (PPALM) from the client intake form or client interview, the therapist can now formulate a client-centered treatment plan.
I’m working on the fourth edition now.
Your opinions will influence the chapter on client documentation.
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Permalink Reply by Ryan B on
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Interesting discussion!
Would a personal practice find web-based software such as SOAP Vault (http://www.soapvault.com/) to create an manage SOAP Notes beneficial?
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Permalink Reply by Alyson C Schlobohm on
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Bianca, I'm going to potentially throw myself under the bus here and tell you that I'm not the best at keeping SOAP notes. I found that, with SOAP notes, I was repeating myself EVERY time a client came in and it became redundant. If a client comes for a relaxation massage and doesn't want any trigger point work or heavy strokes, I make a note once of their preferences. Unless they make changes in the future to their health, preferences or requests, I don't take notes on every visit.
However, if someone comes in with an issue, pain, or problem, I do more documentation. I'll reference areas where I found problems, what works and what doesn't, etc., etc.
I would say overall on the clients where I have not recorded SOAP notes my biggest regret is not remembering their likes and dislikes. In my opinion, a good customer service practice is being able to recall what each person likes.
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