We are sharing another amazing special guest blogger, Amanda Bach, with you! Check it out below!
But did you do your notes? A common phrase heard by student massage therapists as they grind through their clinical practicums. Your supervisor gives you a quick mark and sends you on your way to clean your table and get set for the next. So many things to think of, which muscle attaches where, normal ranges of motion and what was it that I did in that last massage because my patient has asked for that exact same treatment but it’s been over 6 months since their last visit. Phewf. Do you even realize how valuable a simple SOAP note could be? As seasoned RMTs we also can settle in our routines, do you remember; we were taught that documentation is part of our standards of practice for any professional massage therapist. Things like name, date, service type as well as a medical background to ensure your massage is safe and will be of benefit. Areas of focus or areas to avoid. Special Ortho testing and ROM can be fantastic outcome markers and proof of conditions prior to an MVA or even as valuable as helping someone fleeing domestic violence to solidify their burden to “proof of timeline” should they need to testify in court.
COURT!? How would you feel if you found out that a lack of SOAP notes cost your client more covered treatments for their injury obtained at someone else’s fault on the roads? Probably pretty horrible considering most massage therapists spend their careers helping people make progress and get better. If you didn’t chart it did it even happen? And if you did chart it, how well did you describe what happened in a treatment when it potentially becomes a they said/ they said matter. Did you use your cups today? Your patient says their legs are bruised because of it but you could have sworn all you ever massage on this person is their back and neck. What was in your notes? How would your professional body govern such a complaint when you have no notes to share?
I totally get it, we have so many things to do within a shift besides actually massaging for X minutes. Laundry, cleaning and snacks! That being said SOAP notes should be a vital part of our daily routines. I remember back when I was a baby therapist and I was so excited to write my notes up to give me markers in the future, but I was working at a spa and was told repeatedly that “you don’t need notes, most people are just traveling through and you won’t see them often enough for a note to make a difference”. I saw a lot of notes suggesting musical tastes, not to touch their hair during a neck massage all the way to a person’s dog’s name that passed away years ago. Imagine my shock when I met a patient new to me and I asked “How’s little Bernie? Does he like milk bones?” only to be told “I don’t have a dog” and could see them holding back tears.
What types of things should we really be documenting? Animal names and musical favorites, sure those go along way in a customer care aspect but how far would that go in court years later when someone is tasked with the burden of proof.
How they explain their aches and pains, what we see with a visual scan as well as all that valuable information we practiced so hard to pass our exams. Why do we feel too busy to chart a simple progress marker of 10% ROM increase since the beginning of an hour. This is the success our patients are hoping to see and all we have to do is make a quick note. Sure you may give the exact same massage flow to everyone on your table but I bet you that not one person has the same technique/time spent on a particular muscle that might be worth documenting so that when they’re back in 6 months you can review and compare quickly.
Let me share a story with you. I took on a client that had some general aches and pains. Once a month visits with a pretty typical GFB (general full body) flow enjoying medium/firm pressure. After a couple of years with regular treatment, they had their first ankle sprain. We worked diligently to treat and rehab the ankle only for the opposite leg to suffer a tibial fracture. As we were rehabbing that tibial fracture this patient was involved in an MVA to no fault of their own. Now I am 8 years into seeing this patient regularly trying to maintain all the work we had done previously and there are some sciatic symptoms rearing their ugly heads. This particular patient makes a passing comment that I am the only massage therapist they have ever seen or trusted. A few months down the road I inevitably received the request from a lawyer for chart documents. Not just the documents that are related to this MVA but THEIR ENTIRE CHART!!!!!
Now let me ask you, do you have enough robust notes in their file history to be helpful enough to clearly show what injuries were present before the MVA? What about at the time of the MVA? And how about progress since? Are you able to clearly identify markers in their chart when reviewing or do you default to your GFB?
Other times it’s great to know that you’ve done your job is when an insurance company calls to confirm receipt submissions. When you’ve done your notes diligently you’ll readily be able to pull a chart and send it off with minimal time and stress but have you ever considered when a patient is fraudulently submitting with your RMT number? I’ve had a handful of cases over the years when I only saw a person once yet their insurance company is calling to confirm their entire family of 5’s worth of bi weekly massages for the entire year. Well let me tell you; instead of second guessing myself I was able to confidently tell this insurance company that I had only met ⅕ family members and only performed one massage, that I also luckily have robust notes for. This is pertinent information for an insurance company to note to further decrease potential fraudulent claims that ultimately negatively affect our industry as well as extended benefits plan holders across the country.
Most textbooks and online resources are readily available to remind you what goes in each SOAP category, but how efficient are you at jotting it all down while shoveling snacks into your face while the table dries from being sanitized?
In the Documentation Refresher Course for RMT’s we review what’s required by your profession (regulated province or not) and what (and how) notes can be abbreviated in order to make your charting more efficient. Perhaps you work in a large clinic where common shorthand is acceptable. Perhaps having a ledger available for your short hand references should you need to help explain what your HIP-MNRS or LOC-Q-SMATs were and what GFB GSM with XFF means to someone unfamiliar with your secret code. All these considerations and more are discussed in this virtual or in person course offering.
Until then you can stop making notes about their pets names and what they want for birthday gifts or their favorite place to vacation because this information isn’t required.
“Do the best you can until you know better. Then when you know better, do better.” -Maya Angelou
Written by Amanda Bach RMT
-Educator | Facilitator | Mentor