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gpcmassage wrote:I did a search and haven't really found anything that answers my question so I am going to try a new post. I currently use SOAP notes for my charting on all clients. I use pretty much the same form I was taught with in school, and in school they told us ALMOST every time they will be the same. Which they are, but now that I am doing quite a few auto accident cases they really aren't and I don't like my notes are. Everything seems just so repetitive. Obciously the client complaints and the outcomes of the massage are different but the rest just seems boring and the same - I alsmot feel like I am not doing my notes as well as they should be done.
SO..... my question is if anyone would be willing to give me some examples of their soap notes - obviously without any client names.
As an example of what I do now my most "repetitive" notes sound something like this....
S: clent came in for this, c/o this
O: Hypertonic areas found here, TP found here any other areas that need noting - mark areas on body diagrams
A: (here is where things feel repetitive) Cl supine. Warmed neck w/ eff. Stripped SCM, scales and upper trap. Used occiput hold on occiputs. Stretched neck mm. Warmed arms w/ eff. Stripped forarm flexors and extensors, bicep and tricep. Ended w/ compressions. Warmed front of legs w/ eff. Worked quads w/ MFR, palmar gliding, stripping & pet. Worked tibalis w/ MFR, stripped along tibalis. Ended w/ compressions. Worked feet with reflex. (state # of min depending on session length)
Cl prone. Warmed back of legs w/ eff. Worked hams w/ MFR, palmar gliding, pet. Worked gastroc & soleus w/ pet, stripping, palmar gliding, XFF & MFR. Ended w/ compressions. Warmed back w/ eff. Worked traps & rhomboids w/ MFR, XFF, vibration, stripping, palmar gliding, static pressure/TP Therapy. Worked QL's w/ MFR, pet, XFF, stripping & palmar gliding. Ended w/ compressions. Worked glutes w/ kneading. upper body mm didn't respond well, lower body mm responded well to tx. Cl stated she felt great p M.
P: Increase H2O.... do this do that.
That's pretty standard for any client coming in for a full body M, for my AA clients it's usually the same thing but they only get waist up Massage so it's shorter. Any tips or help? Like I said, if anyone is willing to share a copy of their notes to help me expand and be more explanatory that would be great. Thanks!
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