SOAP Notes for Massage Therapy?!
Question: Ok so i'm taking a Massage Therapy Class and one of our assignments this week is to come up with 5 makeup soap notes. We do not really have to do A:Assessment because MT's don't have to assess so basically we have to do SOP notes:-D we have to start our by writing a small paragraph to introduce the case. Here is an example out of the packet can anyone else give me some other ideas?
EX:
A 24 year old male presents to your office complaining of lower back pain after moving into his house over the weekend. Upon examination you find muscle spasm, restricted range of motion and pin point tenderness. The paitent experiences pain upon flexion and right and left rotation.
S(observed only by the patient): Low Back Pain
O(Oberserved by examiner):Restricted range of motion, pin point tenderness, muscle spasm, pain on flexion, right and left rotation.
P(Plan): Swedish Massage and Trigger Point. Come back in one week if pain still persists.
any helps would be GREAT!
Answers: Ok so i'm taking a Massage Therapy Class and one of our assignments this week is to come up with 5 makeup soap notes. We do not really have to do A:Assessment because MT's don't have to assess so basically we have to do SOP notes:-D we have to start our by writing a small paragraph to introduce the case. Here is an example out of the packet can anyone else give me some other ideas?
EX:
A 24 year old male presents to your office complaining of lower back pain after moving into his house over the weekend. Upon examination you find muscle spasm, restricted range of motion and pin point tenderness. The paitent experiences pain upon flexion and right and left rotation.
S(observed only by the patient): Low Back Pain
O(Oberserved by examiner):Restricted range of motion, pin point tenderness, muscle spasm, pain on flexion, right and left rotation.
P(Plan): Swedish Massage and Trigger Point. Come back in one week if pain still persists.
any helps would be GREAT!
Hi Roxygirl! Good question. One thing though, MT's do have to assess. They just can't "Diagnose". Assessment is pretty much a diagnosis for your own personal use in sessions so long as none of that is told to the client (e.g. of Diagnosis would be "It looks like you have a hyper-lordosis in your lumbar spine due to too much anterior pelvic tilt").
So now that we know about assessment, SOAP notes are the ultimate assessment tool to help you remember whats going on with a particular client and therefore make future sessions more productive. It's also a good way to cover your butt in insurance battles.
Subjective: What the client tells you about whats going on
Objective: What you see and feel is going on
Assessment: What happened during the session, What worked and what didn't, possible underlying causes
Plan: Client homework, and your plan for the next session based on what happened this time
Be as specific as you know how to be. Taking your example as a test:
Subjective: A 24 year old male presents to your office complaining of lower back pain after moving into his house over the weekend. What did he do? Did he get pain after doing a particular kind of work? Where is the pain exactly. Is there anything in his medical record that might be a problem or help you figure stuff out? What did his intake form say?
Objective: Upon examination you find muscle spasm, restricted range of motion and pin point tenderness. The paitent experiences pain upon flexion and right and left rotation. Technically pain or tenderness should go in subjective but if this is easier thats fine. Where was the tenderness? Pain upon flexion and right and left rotation of what? The leg at the hip joint? The pelvis at the spinal or lumbo-sacral joints? Where was the spasm? Is the pain Bi-lateral? Is anything inflammed? Etc...
ASSESSMENT: Heres the cool part. Did you get rid of the spasm? What helped the spasm during session? What strokes did you use to help clients Range of motion? Did you use ICE or HEAT? Is the injury sub acute or chronic yet? If it is sub acute, will you work on it and why?
Plan: Client homework could be to ICE the pained area to numbness. Suggested stretching exercises (if you have been trained to give such homework in your scoap of practice). What massage will you use next time. You gonna spend any extra time on a particular spot? Etc...
Hope this helps!
good luck
-M@
Hi Roxygurl. Overall, this is very good. My only suggestion is to be more specific with your objective findings. For example: restricted range of motion (right and left) of "What" ranges of motion? Lumbar? Cervical? What? Additionally, pin point tenderness - exactly where? Lastly, muscle spasm - which muscle(s)? Muscle spasm of the quadratus lumborum is very different than muscle spasm of the rhomboids.
The more detailed, the more specific you are in your work, the more detailed/specific you can be with your notes. And, the more detailed and specific your work, the BETTER your work will be and the BIGGER your practice will be.
Best wishes and good luck.
In all honesty, SOAP notes are basically for your use only. Some therapist go into great detail about what their doing, others dont. I personally dont go into great detail in my notes about a client. If you plan on working in a private practice, this would be a good idea. However, a lot of spas and public massage places dont even make you do SOAP notes.
But, you've got the right idea. Good luck.
When I went for my massage training we had Soap notes and I had a tough time with them. But now in my practice it's a must. If you get involved in any insurance work Soaps are important. And I agree you have to be more specific in regards to which muscles. Luckily on the outside their are computer programs that can help with this though some are expensive. Good Luck on the assignment
Massage Therapist do do assessments and are talked about as functional limitations of the client - like can't stand and brush teeth or can't sit at desk for 20 minutes.
SOAP notes are a very important part of your work. It can save your hide one day when someone comes back and says you did something that hurt them and you have it in your notes that they came in with that pain or something like that. I have a few friends that has happened to. It is for real.
Get the book "Hands Heal" it was written by Diana Thompson, the queen of chart notes