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joshuatenpenny wrote:At first I thought it was interesting that they would require SOAP notes, but then I saw that they say "if a written plan of treatment is requested or required". I can't imagine a client requesting it, and if it is up to your discretion whether or not the charting is required... then what is this really saying? "If you write progress notes, they must follow SOAP format"?
joshuatenpenny wrote:I was particularly concerned about the intake section, because I don't ask for a full list of medications. I ask if the person is on certain sorts of medications (pain relievers, anti-inflammatories, sedatives...) but I feel that the full list of medications is more information than it is within my scope of practice to evaluate. But there is that "as disclosed by the client" line, so perhaps adding "or other medications that might affect your treatment." to my question would be sufficient.
cicerone wrote:The wording troubles me. How will you know if relaxation massage is contraindicated if you don't have an intake form? That is the information included in 3(a) of the exerpt. Is ruling on the "initial evaluation" covered seperately?
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