Suggestions On Documentation Wording - TX Help!!!

Replies to This Discussion

Permalink Reply by Gloria Coppola on November 14, 2009 at 4:37pm

Lisa

You don't need to "list" everything.
You can just put a box perhaps saying " Are there any sensitive or painful regions that you do not want massaged"

If your state requires - You can add at the bottom a statement something to the effect
"Massage is not considered treatment for any medical condition and is for relaxation purposes. Massage is not to be misconstrued as anything sexual and your session will be immediately terminated .

This is some of the types of verbage I have seen on forms. Years ago, I had one man reading it over and over and I realized he did not want to sign. I said obviously you don't want to agree with this, so it is ok if you want to leave. Obviously, he did.

I also use a body map /diagram and people can just mark the places that hurt
You can make your own notes about contraindications and indications for treatment. That would be your S.O.A.P. notes., which is separate from the intake form.

The intake form can include:
Any prescription medications?
Any previous surgeries or injuries?

Feel free to let me review your document and I can make suggestions. You can email it to me.

I hope that is helpful for you.

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Permalink Reply by Susan G. Salvo on November 14, 2009 at 4:47pm

These elements are easily covered in a basic treatment plan.

Walk with me: So John Doe fills out an intake form, you look it over and ask questions regarding its content.

Next, you ask Doe a few questions about his health and goals for the session. He tells you that his shoulders are stiff and sore and that he has a recent injury on his right knee (24 hours ago). Next, he’s been taking Warfarin for about 6 month with no major side effects.

During this interview, you explain to him the possibility of bruising if deep pressure is used to address his shoulder tension. John Doe states that he would still prefer deep pressure, even with this possibility.

Interface this with the number 2 you mentioned:

Parts of the client's body that will be massaged: Focus on client’s shoulder

Areas of the client's body that will be avoided during the session: Right knee because of recent injury

Indications: Deep pressure on his shoulder (possible side effect of bruising was discussed with the client prior to the massage).

Contraindications: Local contraindication of right knee

When I read the italic statement, I interpreted it as the state, whose mission is to protect the public, needs to that you are formulating a treatment plan.

And yes, avoid the “sexual conversation.”

We teach documentation and treatment planning at a school in LA that has a curriculum approved by the Texas.

This is how we deal with the verbiage.

Hope this helps.

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Permalink Reply by Lisa on November 14, 2009 at 4:51pm

Thanks Gloria.

However...i'm thinking that the way the state is positioning it that they are REQUIRING you to list certain verbage. They give you a check list and preempt it with a letter that states:

The Massage Therapy Licensing Program continues to receive complaints regarding problems with the consultation forms used by licensed massage therapists in Texas. Some of these complaints have resulted in an administrative penalty (fine) being assessed against the licensee.

Please use the Checklist which is printed on the back of this letter to quickly review your consultation document and determine whether or not it complies with our current rules. If it does not, or if you are not using a consultation document with every client, you should review the relevant rules at 25 Texas Administrative Code §140.304 and comply with them in future.

i had a friend that i went to school with in CT say something similar as you, in the form of a question as to "there any sensitive or painful regions that you do not want massaged". but my feeling is that the state wants you as the licensee to state where you are massaging and not pose the question to the client.

again, maybe i'm overthinking it...but it seems very specific in what they want you to list in your initial consulation document, but they don't actually give you the verbage (which i think is crap).

I definitely have an area where i ask the client to inform me of areas of pain/stiffness/soreness etc. and i have a place where i specific tell them that massage is not a substitute for a diagnosis or treatment, etc. but i just don't think that's exactly what the state wants.

so currently i've gone down their checklist and have a "disclosure" for each of their items. but 2 got me. so for now...i have

2. During a session, only non-sexual areas of the body will be worked on.

i'm not sure if that's what the state is getting at or not. but i'd rather not list everything i AM massaging (as you've suggested) and really the only areas i'm NOT massaging are sexual areas of the body. so it seems easier to state it that way than the other.

i hate red tape. :)

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Permalink Reply by Lisa on November 14, 2009 at 4:58pm

Thanks Susan...

see i didn't see the state's request as being something that came from "dialog" with the client but rather a disclosure TO the client PRE massage. i do full body massage...therefore i will massage the FULL body. right? (minus the obvious parts). if it's the state wanting this for the INITIAL consultation document than what i massage during any given session can change. and i always thought that the initial consultation document was just that...and remains the same until the client states things have changed.

*insert sigh here*

Susan G. Salvo said:

These elements are easily covered in a basic treatment plan.

Walk with me: So John Doe fills out an intake form, you look it over and ask questions regarding its content.

Next, you ask Doe a few questions about his health and goals for the session. He tells you that his shoulders are stiff and sore and that he has a recent injury on his right knee (24 hours ago). Next, he’s been taking Warfarin for about 6 month with no major side effects.

During this interview, you explain to him the possibility of bruising if deep pressure is used to address his shoulder tension. John Doe states that he would still prefer deep pressure, even with this possibility.

Interface this with the number 2 you mentioned:

Parts of the client's body that will be massaged: Focus on client’s shoulder

Areas of the client's body that will be avoided during the session: Right knee because of recent injury

Indications: Deep pressure on his shoulder (possible side effect of bruising was discussed with the client prior to the massage).

Contraindications: Local contraindication of right knee

When I read the italic statement, I interpreted it as the state, whose mission is to protect the public, needs to that you are formulating a treatment plan.

And yes, avoid the “sexual conversation.”

We teach documentation and treatment planning at a school in LA that has a curriculum approved by the Texas.

This is how we deal with the verbiage.

Hope this helps.

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Permalink Reply by Susan G. Salvo on November 14, 2009 at 5:51pm

Bear in mind that this is the way I do thing, but most sources I looked at (when researeching for what to include in textbooks) stated that the minimum required client documentation is:

1) Client intake form (health history, medical history, whatever you want to call it).

2) Treatment plan (which represents the dialog with the client BEFORE the session; it is your treatment strategy and is based on client data, your professional skills and training, and legal scope of practice, just to have a few). For the most part, this plan doesn’t change much unless your client’s health or treatment goals change.

3) Informed consent (client’s authorization for professional services, and may include your credentials, description of the styles or methods you utilize, expectations and potential benefits of these methods and their potential risks and possible undesirable side effects, a little about your cope of practice, right of refusal, stuff like this – this is presented and discussed during the initial visit only unless you have incorporated a new method not reflected in the initial informed consent document. The exception to this rule is if you do massage to female breast, which often requires a separate consent. If you have ever gone into the hospital, the informed consent is what you sign to cover almost everything done to you. You rarely sign a new one unless a different provider gets involved with your care.

Got a little off track, sorry. But you ask important questions and many therapists don't understand the difference between informed consent and the treatment plan,

But the plan does represent the dialogue BEFORE the session.




Lisa said:

Thanks Susan...

see i didn't see the state's request as being something that came from "dialog" with the client but rather a disclosure TO the client PRE massage. i do full body massage...therefore i will massage the FULL body. right? (minus the obvious parts). if it's the state wanting this for the INITIAL consultation document than what i massage during any given session can change. and i always thought that the initial consultation document was just that...and remains the same until the client states things have changed.

*insert sigh here*

Susan G. Salvo said:

These elements are easily covered in a basic treatment plan.

Walk with me: So John Doe fills out an intake form, you look it over and ask questions regarding its content.

Next, you ask Doe a few questions about his health and goals for the session. He tells you that his shoulders are stiff and sore and that he has a recent injury on his right knee (24 hours ago). Next, he’s been taking Warfarin for about 6 month with no major side effects.

During this interview, you explain to him the possibility of bruising if deep pressure is used to address his shoulder tension. John Doe states that he would still prefer deep pressure, even with this possibility.

Interface this with the number 2 you mentioned:

Parts of the client's body that will be massaged: Focus on client’s shoulder

Areas of the client's body that will be avoided during the session: Right knee because of recent injury

Indications: Deep pressure on his shoulder (possible side effect of bruising was discussed with the client prior to the massage).

Contraindications: Local contraindication of right knee

When I read the italic statement, I interpreted it as the state, whose mission is to protect the public, needs to that you are formulating a treatment plan.

And yes, avoid the “sexual conversation.”

We teach documentation and treatment planning at a school in LA that has a curriculum approved by the Texas.

This is how we deal with the verbiage.

Hope this helps.

• ▶ Reply

Permalink Reply by Lisa on November 14, 2009 at 6:07pm

thanks Susan.

I rarely do a "treatment plan" prior to my first session with a client. i don't feel i can adequately decide on a treatment plan when i haven't palpated their muscles yet. we all know that where a client feels pain isn't always the cause so how can one come up with an "initial" treatment plan having never worked with the client?

when a client comes in for the first time, i have already received their intake form via email and have already discussed with them what's bothering them, usually through email correspondence prior to the appointment. in the office, i go over my "what not to wear" speech, my "just because you feel it here" speech and my "why full body" speech. I also usually ask their experience with massage. then i get them on the table. i have them fill out an initial questionnaire so i can get a glimpse of how they are carrying themselves throughout their days and give me an idea of their sleep/exercise/stress patterns. but i don't go into what i'm going to treat. i tell them my session is a full body massage and we go from there based on what i find.

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Permalink Reply by Gloria Coppola on November 14, 2009 at 6:36pm

Lisa,
Don't you know any LMT's in texas that can help you with this specifically! I'm sure there must be some on this site that can tell you how to word it for your state requirements.

I can't see them wanting you to list everything as that would be a very long document.
It is possible you are over thinking it .

Can't your school tell you how it should be done? You stated in Susan's reply that you have a document from the state that lists what they want????

Sorry I can't help specifically for your state. Can you call your licensing board for help?

Lisa said:

thanks Susan.

I rarely do a "treatment plan" prior to my first session with a client. i don't feel i can adequately decide on a treatment plan when i haven't palpated their muscles yet. we all know that where a client feels pain isn't always the cause so how can one come up with an "initial" treatment plan having never worked with the client?

when a client comes in for the first time, i have already received their intake form via email and have already discussed with them what's bothering them, usually through email correspondence prior to the appointment. in the office, i go over my "what not to wear" speech, my "just because you feel it here" speech and my "why full body" speech. I also usually ask their experience with massage. then i get them on the table. i have them fill out an initial questionnaire so i can get a glimpse of how they are carrying themselves throughout their days and give me an idea of their sleep/exercise/stress patterns. but i don't go into what i'm going to treat. i tell them my session is a full body massage and we go from there based on what i find.

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Permalink Reply by Lisa on November 14, 2009 at 7:00pm

Thanks Gloria. i am hoping one of the MTs from Texas will post up.

i also figured it was a good general discussion. :)

i DO believe that the state should provide it if it's gonna dictate something be there.

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Permalink Reply by Erica Olson on November 15, 2009 at 12:48am

Personally, I would say that the breasts and genitals would be avoided, not "non-sexual" areas of the body. Sensuality is a much broader base than simply breasts or genitals--the back of the neck, the buttocks, the abdomen, the hair, the ears, etc. All of those can be parts of the body that cause sexual arousal to the owner--under the right conditions. I would just put in a regular disclaimer regarding genital massage, printed as default on your SOAP notes. Breast tissue can encompass a fairly wide area, so I would hate to avoid the pectorals simply because a woman had breast tissue that extended that far (as do many).

Lisa said:

2. During a session, only non-sexual areas of the body will be worked on.

i'm not sure if that's what the state is getting at or not. but i'd rather not list everything i AM massaging (as you've suggested) and really the only areas i'm NOT massaging are sexual areas of the body. so it seems easier to state it that way than the other.

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Permalink Reply by Laura Allen on November 15, 2009 at 11:29am

I don't know the Texas law, unfortunately, but as I file a lot of insurance in my office, we document the heck out of everything. And earlier this week, we got a dr. referral for breast massage. I have several therapists in my office who do pelvic floor work, and I did so myself back when I was seeing clients regularly. You also can't really help anyone with low pack pain or sciatica unless you work the gluts. I've never hesitated to work areas that people might consider "sensual"; with informed consent of course.

In NC, we actually have the right to work inside body cavities below the waist (prostate massage and intravaginal massage), providing that it is 1)prescribed by an MD, 2)specific additional informed consent has been given 3) a third party must be in the room, and 4) the therapist must be trained in performing that work.

Last year I tried offering a class in visceral and pelvic massage taught by a chiro and his PT wife, that didn't even involve any internal massage, and I didn't get a single person to sign up for it. Too many people are afraid of doing pelvic work because they are afraid it will be misconstrued.

When I get back to my office tomorrow I'll be glad to send you an example of how we document sessions.

Erica Olson said:

Personally, I would say that the breasts and genitals would be avoided, not "non-sexual" areas of the body. Sensuality is a much broader base than simply breasts or genitals--the back of the neck, the buttocks, the abdomen, the hair, the ears, etc. All of those can be parts of the body that cause sexual arousal to the owner--under the right conditions. I would just put in a regular disclaimer regarding genital massage, printed as default on your SOAP notes. Breast tissue can encompass a fairly wide area, so I would hate to avoid the pectorals simply because a woman had breast tissue that extended that far (as do many).

Lisa said:

2. During a session, only non-sexual areas of the body will be worked on.

i'm not sure if that's what the state is getting at or not. but i'd rather not list everything i AM massaging (as you've suggested) and really the only areas i'm NOT massaging are sexual areas of the body. so it seems easier to state it that way than the other.

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Permalink Reply by Lisa on November 15, 2009 at 11:46am

well so here's my last page of my initial consultation document. just so you can see everything...i have 2 pages before this that are info taking documents. 1-6 and 10 all are specific to the check list the state provided. The others were ones i modified from school

The following disclosure is in adherence with the Department of State Health Service, Massage Therapy Licensing Program:
1. Client agrees to an integrated therapeutic massage session. As such, various techniques and modalities will be utilized throughout the session in order to effectively manipulate the soft tissue. These techniques and modalities include Swedish, Sports, Cross Tissue, Deep Tissue, Accupressure, Energy Balancing, and Remedial massage.
2.During a session, only non-sexual areas of the body will be worked on.
3. At no time will the therapist engage in breast massage of female clients without the written consent of the client.
4. Draping will be used during the session, unless otherwise agreed to by both the client
and therapist.
5. If uncomfortable for any reason, the client may ask the therapist to cease the massage and the therapist will end the massage session.
6. Client understands the massage therapist is neither trained nor licensed to provide medical treatment to diagnose, prescribe drugs or medicines, perform spinal or other joint manipulations, nor any other service which a license to practice medicine, chiropractic, naturopathy, physical therapy, or podiatry is required by law.
7. Client, here in, has been provided with a description of services. Client understands and agrees to the purpose, nature, and duration of the proposed service, and consents to receive this service.
8. Client understands that there can be remote risks associated with this work. Client acknowledges that the therapist will not be responsible for any injury arising because of some unreported condition and/or concern.
9. Client acknowledges being given the opportunity to ask questions before receiving any work, and to question or interrupt the work at any point after the session begins.
10. An individual who wishes to file a complaint may write to: Complaints Management and Investigative Section, P.O. Box 141369, Austin, Texas 78714-1369 or call 1-800-942-5540 to request the appropriate form or obtain more information.
Client acknowledges having read and understood this document.

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Permalink Reply by Erica Olson on November 15, 2009 at 12:16pm

Man, I would love to take a class like that, and/or do internal massage. I'm the kind of person that really enjoys a challenge and am happy to, uh, "go boldly where no man has gone before." Well, not "no man," but you get the idea. :D

Where does one find information about laws regarding internal massage on a state-by-state basis? Any suggestions?

I would love to see examples of how you document, Laura.

Laura Allen said:

In NC, we actually have the right to work inside body cavities below the waist (prostate massage and intravaginal massage), providing that it is 1)prescribed by an MD, 2)specific additional informed consent has been given 3) a third party must be in the room, and 4) the therapist must be trained in performing that work.

Last year I tried offering a class in visceral and pelvic massage taught by a chiro and his PT wife, that didn't even involve any internal massage, and I didn't get a single person to sign up for it. Too many people are afraid of doing pelvic work because they are afraid it will be misconstrued.

When I get back to my office tomorrow I'll be glad to send you an example of how we document sessions.

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