SOAP notes

[jimswife]

I have been wanting to ask this for awhile now but have chickened out because I know I'm going to sound stupid. But I the only way I'm going to find out is if I ask. Right?

Okay.... so I'm fairly new to writing SOAP notes. And I'm am struggling big time! First, I don't know what to call the "knots" that I feel when I'm writing. My other problem is that I'm still not feeling alot of "stuff" when I'm massaging. The clients aren't coming in with issues for me to work out for them. They just want a relaxation massage. So if I'm not really feeling anything other than a knot here and there, maybe tight traps or something what the heck do I put in the SOAP notes????

I'm getting frustrated with myself right now because I'm just not feeling things yet. I am trying to, and maybe that's the problem.

[Ding]

Kudos to you, Jimswife, for having the courage to post what you thought was a "stupid question." -- and let me say that there IS no such thing as a stupid question!!

I can only tell you how I do my notes, and my practice is not particularly technical, so perhaps others will chime in with comments/suggestions too. I refer to those 'knots' as TP (trigger points), and if a certain muscle area is 'tight', I write HT (hypertonic) and name the muscle (and include L or R or BL). I also include areas of tenderness that are discovered during the massage. I also have a section in my notes where I include "comfort" preferences (such as if they like extra blanket, a certain bolster, NO aromatherapy, music preference, no scalp work, etc). Note that I only include things that they've commented on liking/disliking, so I can be sure to have things they way they prefer without having to be asked each time.

I hope this is helpful. Please know that as you gain more experience, you will have more confidence and understanding with what you are feeling. Your hands will begin to know what 'feels' normal and what doesn't.

[Ding]

oh, I forgot to add that I also include ROM information, if it's limited on one side more than the other, or particularly limited. I don't do anything detailed or scientific (measuring angles, etc), just "ROM limited, cervical rotation to L" for example.

[jimswife]

Thank you Ding. Your post was helpful and encouraging. I have been writing HT for tight muscles and TeP for tender points when I feel something. But then I started thinking that I should write adhesion or fibrous tissue?? I have been including R, L in my notes. So I've been doing okay as far as that. But for the most part it seems like my soap notes are really brief and basically the same. HT traps, rhomboids,infraspinatus or QL. I do include stuff the client tells me specifically as far as whatever tightness/pain they may have. I too have included personal notes about what the client likes as far as a particular technique they do or don't like. I have been putting that information in P. Where do you usually include this information in your notes?

[JasonE]

Are your instructors not teaching you how to write SOAP notes? I would take your questions to them, too. They might also be able to help you connect what you feel with how you write about it.

Depending on how your client records are set up, a client's preferences regarding pressure, draping, music, etc. can be put in a permanent note that is consulted every time they return (in addition to the most recent SOAP notes), or you can keep copying it into the "P" (Plan) section of each SOAP you write. Our practice has a permament note for stuff like that so our MTs don't have to keep rewriting it, though they can certainly change it as the client's preferences change.

If you are only doing basic full-body relaxation, many of your notes will be similar, at first. However, what kind of intake are you doing? Are you asking about injury history and medical conditions? Do you note when they were in MVAs (moving vehicle accidents) and the injuries sustained in each? Do you ask whether they are on any medications or if they have been prone to headaches, bruxism (teeth grinding), etc.? Even if they "just want relaxation", the information obtained in a good, detailed intake may completely change how you go about helping them to relax. It may even inspire you to convince them to let you do focused work on a specific problem area instead, as that may provide much greater relief and relaxation than any full-body session. Note what you learn during the intake in the "S" (Subjective) section of your notes.

If you do client ROM, posture, movement, or orthopedic assessments, note what you learn in the "O" (Objective) section of your notes. This is also where you note the location and types of hypertonic tissues, tender points, trigger points, etc. If you don't know how to feel the difference between fascial adhesions and other problems, note "Possible fascial adhesion(s) at ______." If you find "crunchy", "ropey", etc. tissue feel, note it with the adjective(s) that best describe it.

"A" (Assessment) is where you note tissue changes during the session, whether the client relaxed or not, whether their symptoms changed, etc.

"P" (Plan) is primarily used for noting what you recommended to the client after the session, such as when to return, certain types of work or strategies to explore next time, whether they should see a medical professional for something, etc.

[maestra]

You might try this book...

Hands Heal: Communication, Documentation and Insurance Billing for Manual Therapists:
http://www.amazon.com/Hands-Heal-Commun ... b_title_bk

[JasonE]

I just came across an outline for SOAP notes from when I was in massage school. You will notice that it is designed to help you conduct a thorough intake prior to the massage and a followup conversation afterward. Please feel free to make use of it.

SOAP Notes Condensed Outline

S
1. Are there any changes in your health history?
2. What is your goal for today’s massage?
3. Are there any areas you would like me to focus on? Emphasis on?
4. Does your job have you doing any repetitive actions / motions? Do you play any sports?
5. What are your symptoms today?
6. Where are your symptoms today?
7. When did your symptoms begin?
8. How often do your symptoms occur?
9. Rate your pain/discomfort/tension/irritation on a scale of 1-10, Today / Best Day / Worst Day:
10. What makes your symptoms better? How often do you do these?
11. What makes your symptoms worse? How often do these happen?
12. Do you feel that you have any restrictions in your ROM? If yes, where?
13. Do you feel limited in any of your daily activities? If yes, what activities?
14. Are you currently seeking any other treatments besides massage? How often?
15. How was your last massage? What did you like? What didn’t you like?

O
1. Session Length:
2. What position did client start at? How long in each position? Did client have preference? If yes, what position?
3. Was any special bostering required? If yes, what?
4. How did tissue feel? (quality of tissue, name specific muscles, compare L/R)
5. Overall, how did tissue feel? How did majority of tissue feel?
6. Techniques used (and where):
7. Describe client’s breathing
8. Describe client’s skin
9. Was client able to relax? Did client fall asleep?
10. How well did client move on the table? Did they require help?
11. Where did you find Trigger Points? (list muscles)
12. What was the referral pattern? (be detailed about where it went)
13. Did client say referral pattern was familiar? (have they felt it before?)
14. What words did client use to describe the referral sensation?

A
1. Did the tissue change after your techniques? How did it feel afterwards?
2. Any change in client’s breathing?
3. Any change in client’s quality of movement? Or ROM?
4. What did client say after the massage? How did they feel?
5. Did your client’s symptoms change? What did they say?

P
1. Did you encourage your client to drink more water?
2. Any ideas for additional massage sessions? Specific muscles/areas? Anything else?

[jimswife]

Thank you so much!!

[GaryA]

SSS, unfortunately my school requires us to make the notes brief as possible--abbreviations, symbols. So our SOAPS consist of a list of TrPs, Adh, HT,etc along with location as abbreviated as possible for understanding. There's a tendency among the students to mirror the issues noted the last time they came for a massage--I suppose they feel that they will be criticized if they don't find as many TrPs as the last student to treat the client. Admittedly, doing so (since everyone else reports such a long list of stuff) is hard to resist. But I have, so far, and, yes, I have been mildly criticized for not "being thorough." I reply, that, hey, the last guy did such a good job, this time the rhomboid, etc, was in fine shape. I get excellent grades on my SOAPS, so I must be doing alright.

I think your soap methodology is far more sensible; to me, it is logical to assume an MD will prefer plain English/medical terminology to a long list of symbols he'd have to look up to understand.

An unrelated question. I've noticed that clients who regularly visit the day student clinic have much difference likes & dislikes than those who visit the night class student clinic. Night clients as a group want really deep pressure; day clients will jump off the table if [pressure is greater than light petrissage. IOW, they've become conditioned: night classes are DT and NMT, day classes are Swedish and the energy modalities.

[Rozax]

I wonder if my classmates came across the list that Jason posted. Don't get me wrong, it's dead useful! It's just that, I'd roll my eyes when I'd pick up my client's clip board and see nothing more than "drink more water", "increase water intake", and the infamous "↑ water" going back several weeks. It was a good day when my instructor said, "Look, I'm glad you're talking to your clients about the importance of staying hydrated, but there's more to planning than that."

[JasonE]

SSS, unfortunately my school requires us to make the notes brief as possible--abbreviations, symbols. So our SOAPS consist of a list of TrPs, Adh, HT,etc along with location as abbreviated as possible for understanding. There's a tendency among the students to mirror the issues noted the last time they came for a massage--I suppose they feel that they will be criticized if they don't find as many TrPs as the last student to treat the client. Admittedly, doing so (since everyone else reports such a long list of stuff) is hard to resist. But I have, so far, and, yes, I have been mildly criticized for not "being thorough." I reply, that, hey, the last guy did such a good job, this time the rhomboid, etc, was in fine shape. I get excellent grades on my SOAPS, so I must be doing alright.

I think your soap methodology is far more sensible; to me, it is logical to assume an MD will prefer plain English/medical terminology to a long list of symbols he'd have to look up to understand.

An unrelated question. I've noticed that clients who regularly visit the day student clinic have much difference likes & dislikes than those who visit the night class student clinic. Night clients as a group want really deep pressure; day clients will jump off the table if [pressure is greater than light petrissage. IOW, they've become conditioned: night classes are DT and NMT, day classes are Swedish and the energy modalities.

Actually, medical notation is chock full of standardized abbreviations and symbols. It saves a lot of writing and may result in much greater clarity than plain English. There are books of standardized medical notation that may be used as references for writing SOAPs that could easily be read by medical professionals.

Here are some links to relevant articles/content - notice the examples provided:

http://en.wikipedia.org/wiki/SOAP_note

http://metaot.com/glossary

http://www.medicalassistant.net/soap_note_example.htm

http://www.physicaltherapynotes.com/201 ... -note.html

In my experience, most MTs are not sufficiently familiar with standardized abbreviations to write "medical-grade" SOAP notes, but it's a skill that should be cultivated if you wish to work with clinical cases and/or insurance billing. It may also help set you apart from other MTs when presenting yourself to medical professionals for employment, professional discourse, and/or networking for referrals.

[JasonE]

I wonder if my classmates came across the list that Jason posted. Don't get me wrong, it's dead useful! It's just that, I'd roll my eyes when I'd pick up my client's clip board and see nothing more than "drink more water", "increase water intake", and the infamous "↑ water" going back several weeks. It was a good day when my instructor said, "Look, I'm glad you're talking to your clients about the importance of staying hydrated, but there's more to planning than that."

Your instructor is absolutely correct! Things like, "Start prone with hip bolster for LB work. Review AIS for hips/glutes at end of session" would be useful reminders to yourself (or other MTs you work with, that share SOAPs) the next time that client came in. It's a way to communicate important thoughts to whoever works with that client next, so that they may help the client more effectively.