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I'm curious to know how many therapists really write out SOAP notes for their clients.  If you do take notes, how do you go about crafting a plan for your clients - is it even worth your time if you're not sure the client is going to come back?

 

I run a website MassageCRM with the goal of making it easy to record SOAP notes, but I also aim to make it effective to do so.  I wonder if some therapists don't take notes or don't go back and refer to them later - and if so, I'd like to know why.

Tags: Massage, MassageCRM, Notes, Plan, SOAP

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I write out notes for each of my clients.  I do massage, MFR and CranioSacral Therapy so I've made a custom page for me to take my own style of notes on.  I do refer back to them - not every session but most of the time.  It's really helpful to me!

I hand-write the notes; I do a lot of electronic communication and use the computer for a lot of things but I like the hand written notes for some reason.  Also, since client notes are confidential I would be concerned about security.  If you have a way to make online notes secure that's a good thing!

I like it that you do automatic reminders for clients, and I like the option to color in parts of the body.  It looks like you've got some good ideas!

Thanks for taking a look at the site, Therese.  When you write out your notes, how long are they usually?  Do you put them in SOAP format?

I understand what you mean about security.  However, if the proper steps are taken, it's possible to make a website just as secure or more secure than paper records at the office.  I know that's a short answer to a serious question, but I just wrote out the long answer and it seemed like a lot of hot air and jargon :)

I dont have any time for any notes....we a have ten minutes between appointments to clean up the room for the next therapist and client...the computer moves us to different rooms...I tell my clients that Im doing any medical type work on to simply remind me of what we are doing on any follow up visits.

Hi Gordon,

  That's a good point and one that I've heard before.  Angie only gets a few minutes between appointments on a busy day and doesn't have time to take detailed notes (in your case, any notes at all).  How often do your clients remember what you told them on their next visit?

I explain everything that Im doing to certain clients that have pain problems...So they have a total understanding as to what and why I do what I do...And usually they have experienced a great amount of benefit from their first visit, and are coming in on a follow up, and are excited to be or get out of pain..They remember because most of them have had zero to no benifit from other health care providers they have seen...Like a guy yesterday..  He has had pain in his hip for years..I worked with him for an hour yesterday.. discovered and fixed his problem...he is coming in on a follow up on Monday..I told him to remind me as to what we did... He said...dont worry..I will remind you...I feel great.. this is awesome...they keep me up to date... All my regulars that come in for their regular monthly visit...no need for notes..if there is , they remind me... I teach my clients...That being said..Notes would be better...but its not a perfect world.

Jason Huie said:

Hi Gordon,

  That's a good point and one that I've heard before.  Angie only gets a few minutes between appointments on a busy day and doesn't have time to take detailed notes (in your case, any notes at all).  How often do your clients remember what you told them on their next visit?

The office that I am working at does not have the massage therapists write SOAP notes.  At first I was thrilled to be away from that.  But there are times I wish I had records to look back on.  The main reason is that there isn't time between clients to write notes.  We have about 5 minutes to change the sheets, wash up and greet the next client.  But at the end of the shift we probably could write notes for the clients we saw that day.   Probably very brief notes about the session.  Maybe about how the client was feeling that day, what technique seemed to work and how they felt after the previous session. 

I think that's it's intersting that you were happy to be away from SOAP notes, but now wish you had them to look back on.  What was it about the note taking that you disliked?  Sometimes I find that just the idea that I "have" to do something makes me dislike it...

Jimswife said:

The office that I am working at does not have the massage therapists write SOAP notes.  At first I was thrilled to be away from that.  But there are times I wish I had records to look back on.  The main reason is that there isn't time between clients to write notes.  We have about 5 minutes to change the sheets, wash up and greet the next client.  But at the end of the shift we probably could write notes for the clients we saw that day.   Probably very brief notes about the session.  Maybe about how the client was feeling that day, what technique seemed to work and how they felt after the previous session. 

That's exactly what it was.  Having to do it.  Granted my only experience with SOAP notes was in school clinic.  But I dreaded it.  At that time I was only doing relaxation massage.  And was feeling like I had to find something wrong with each client and document it.  I have yet to have a client that doesn't have tight traps.  But in school I felt like I needed to find more and come up with this elaborate treatment plan or something.  But now.... I just want to know what other therapists have done if they maybe worked on a different area.  Especially if the client tells me the felt better or worse.  It would be nice to know what worked!  

Now if I had a document that can be filled in with brief notes in like 30 seconds I would be all over that!  Something with a diagram where I could circle this and that with a brief note would be perfect.    

Jason Huie said:

I think that's it's intersting that you were happy to be away from SOAP notes, but now wish you had them to look back on.  What was it about the note taking that you disliked?  Sometimes I find that just the idea that I "have" to do something makes me dislike it...

Jimswife said:

The office that I am working at does not have the massage therapists write SOAP notes.  At first I was thrilled to be away from that.  But there are times I wish I had records to look back on.  The main reason is that there isn't time between clients to write notes.  We have about 5 minutes to change the sheets, wash up and greet the next client.  But at the end of the shift we probably could write notes for the clients we saw that day.   Probably very brief notes about the session.  Maybe about how the client was feeling that day, what technique seemed to work and how they felt after the previous session. 

If only there were such a system.  Perhaps if it were online.....one might call such a system MassageCRM ;)

Seriously though, that's exactly what I had in mind when I created MassageCRM.  SOAP notes can be very quick notes to yourself so that every visit can build on the one before it.  We also have the diagram you mentioned that gets saved for every massage appointment. 

Jimswife said:

That's exactly what it was.  Having to do it.  Granted my only experience with SOAP notes was in school clinic.  But I dreaded it.  At that time I was only doing relaxation massage.  And was feeling like I had to find something wrong with each client and document it.  I have yet to have a client that doesn't have tight traps.  But in school I felt like I needed to find more and come up with this elaborate treatment plan or something.  But now.... I just want to know what other therapists have done if they maybe worked on a different area.  Especially if the client tells me the felt better or worse.  It would be nice to know what worked!

Now if I had a document that can be filled in with brief notes in like 30 seconds I would be all over that!  Something with a diagram where I could circle this and that with a brief note would be perfect.

Jason Huie said:

I think that's it's intersting that you were happy to be away from SOAP notes, but now wish you had them to look back on.  What was it about the note taking that you disliked?  Sometimes I find that just the idea that I "have" to do something makes me dislike it...

Jimswife said:

The office that I am working at does not have the massage therapists write SOAP notes.  At first I was thrilled to be away from that.  But there are times I wish I had records to look back on.  The main reason is that there isn't time between clients to write notes.  We have about 5 minutes to change the sheets, wash up and greet the next client.  But at the end of the shift we probably could write notes for the clients we saw that day.   Probably very brief notes about the session.  Maybe about how the client was feeling that day, what technique seemed to work and how they felt after the previous session.

Aloha all,

I have consistently writtten chart notes for most of my clients for the past 16 years.  I've been in private practice the entire time.  About 80% of my clients pay cash/check at time of service, the other 20% are insurance, some but not all of which require chart notes.  

It's always been my personal choice, and my discipline, to write chart notes because the process of reviewing the session in my mind is beneficial to me.  I do all 90-120 minutes sessions, and I have at least an hour off between clients.  (I have a home office.)  I spend 5-10 minutes writing notes for each session.

It's definitely best if I write my notes for one client before seeing the next.  I find that I remember details of a session quite well over a period of hours, or even a day or two up until the point that I give someone else a session.  After I give another session my memory of a previous session quickly gets fuzzy.

I wrote my notes by hand for years; they were a mess.  I've been typing them for the past few years and this works much better.  I use a Word document with my self created simple SOAP format and save the notes to my desktop.   

Heres an example, name and DOB blanked out of course:    The first section stays the same from session to session, unless something important happens that I want to add to that section so I see it everytime I write notes for this client's session.                                 

Client:  NAME, DOB xx/xx/xx, female, active, loves to dance, lawyer in private practice, long term depression, late March 2009 began taking prozac for first time.  First visit to me on 4/11/09, 3 MVA: 1991, 2005, 2008, 9/30/2011

Mar 2, 2012

S:  neck recovering from last week’s set back.  Low back irritation.

TX: ML session  

Observations:

  • R shoulder, ribcage, arm, clavicle and neck are all tight
  • Releasing R pec major helped free R shoulder
  • Tension jerks in vertebrae in midback, L side
  • The neck and R arm connection is strong.
  • Hip rotation better than it often is, BL

Assessment: 

  • Moves more easily after massage,  

Plan:  massage x 1 week                                         

  

Writing notes is a task for me; it's useful, but not at the top of my list of fun things to do.  It's a breath of fresh air when I occasionally do a session for a family member or at a volunteer event and don't even think about writing  notes.

 

Warm wishes to all,

Barbara Helynn Heard

www.lomilomi-massage.org

They aren't long; it only takes me a short time to write them up.  They aren't in a standard SOAP format.  I've attached a PDF of my form I made.  It's not perfect and I'm constantly tweaking it but for the most part it works for me.

My husband is a computer guy and it doesn't take long for my eyes to glaze over when he goes into detail about what he's working on! :)  I believe you when you say that you can make the website secure.

I am fortunate (well, I've worked hard to set it up this way!) to work for myself from home.  I leave 30 minutes between clients when at all possible.  I don't have Barbara's wonderful discipline to do notes right away!  I will get there... :) Like Barbara, it's not my favorite thing to do; however, when I review my notes before my clients get here I'm really glad I did them!  I try not to have more than 3 clients a day.  I ended up with 4 tomorrow though...It's easier to take notes given that situation. I really feel for you guys that are booked solid with no time in between.  I wouldn't last long in that situation; kudos to all of you who can do it.


Jason Huie said:

Thanks for taking a look at the site, Therese.  When you write out your notes, how long are they usually?  Do you put them in SOAP format?

I understand what you mean about security.  However, if the proper steps are taken, it's possible to make a website just as secure or more secure than paper records at the office.  I know that's a short answer to a serious question, but I just wrote out the long answer and it seemed like a lot of hot air and jargon :)

Attachments:

Aloha Therese,  I dont' always get my notes done right away.  But my notes are better quality when I do.  Once in a while I write "waited too long to write notes" in the observation section.  I am however disciplined always write at least skeletal notes so that I have a record of when I saw clients, and I write specific notes I'm satisfied with most of the time - maybe 90%

 

Aloha,

Barbara helynn

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