SOAP charting - how often?

[mandi nic]

In school we were taught to do SOAP notes - a fresh sheet - after each and every session with a client. Does anyone just update SOAP notes from the last session? Most of my clients are there for relaxation, and if nothing about their subjective/objective has changed, except that they feel "reduced stress", and I do pretty much the same routine on them, I would think that I could just note that and date it instead of starting a new chart over each time.

 

[rae rae shorty]

I do SOAP (kinda) every session. I have two different forms. One is for prescription massage--if I'm working with a doc or with insurance. These are my separate notes only. They don't go in the file, I use them to update my WinCity SOAP and put a new sheet in the file.

The other is 3 to a sheet, has a body map, and a few lines for notes. I use this one for my self-referred, non-injury clients, or those who come with only one or two complaints, and if I am not billing insurance or working with a PCP.

The second method takes about 2-3 minutes max to update. Usually I am done by the time they come out of the room after their session. I also use these sheets to keep track of their packages, or if they have a discount coming in the next session, either from rebooking or from a referral.

I keep each returning client in their own file folder with their "code" on the outside, which is simply the first 3-4 letters of the last name, first 2-3 letters of the first name, and the year I originally saw them.

New clients get their own folder only after the second visit. All new clients' intakes go into a main file labeled "First Visit." This way if they are one-ers, I don't waste the file space. The notes for the first visit go on the back of the intake, along with any preferences I might wish to note.

BUT... I do mostly "therapeutic" work (somehow that word bugs me...isn't relaxation therapeutic too? :? ) ... very little "relaxation" work, so I don't have a routine.

I have one client that comes in for a routine. She has no issues, and no complaints. Her notes look like this:

4/12/6 FBSWM + Neck
4/30/6 FBSWM + Hands
5/25/6 FBSWM + Extra Feet
6/10/6 FBSWM + Cold, blanket.
8/10/6 FBSWM + New grandson

etc. I have a year history on one sheet of paper.

YMMV, but I do believe in most cases, it's appropriate to keep notes of some sort.

 

[Office Monkey]

SOAP charting - how often?

In school we were taught to do SOAP notes - a fresh sheet - after each and every session with a client. Does anyone just update SOAP notes from the last session? Most of my clients are there for relaxation, and if nothing about their subjective/objective has changed, except that they feel "reduced stress", and I do pretty much the same routine on them, I would think that I could just note that and date it instead of starting a new chart over each time.

I vote for daily notes.

I take my massage session "SOAP's" somewhat different than a physician would, in that I don't use the SOAP boxes for quite the same thing. I do believe in always charting in one form or other.

So, here is my little method of SOAPing for a massage client. Just remember the SOAP aren't going to exactly match up, but I use Massage Office, and they have the SOAP words that come up on each chart, so this is how it looks.

First let me put a few things in perspective.

I too work mainly in a "therapeutic" practice setting with occasional relaxation clients. I always try to throw just a little relaxation work into my therapeutic work, and generally even the relaxation clients get a little therapeutic/deeper work. I think the reason we differentiate therapeutic from relaxation work is not because "relaxation work" isn't therapeutic, but because more people understand that "therapeutic work" is going to hopefully help them in solving their problem, where as much relaxation work, will just make them "feel good". By the time they get to our office, they are generally looking for more than a "feel good" massage. I do hope that makes sense.

So, we have a folder for fist time clients who don't have a track record with us or a script from their doctor. These clients stay parked in this folder until they return at least once and maybe a few more times. I handwrite a chart note on the back in my general SOAP-ish form and when they become someone who will be returning I put them into the Massage Office and they get a "real" folder and the handwritten notes are then entered into the computer.

My folder system is color coordinated. So if a new client is coming from a doctor referral, then depending on the doc, they are going to get a colored folder immediately on their first visit. If they are new as mentioned in the above paragraph, they get parked for a bit. Our personal clients (non-doc referrals) have a different color folder and they have a color coded tab on the outside of the folder to notate which of us (husband or myself or both) they are seeing.

So, now we have an established client. The SOAP's will "look" something like this - unless I think there needs to be a lot more detail for some reason.



S: Client presents today with complaint of pain in the right shoulder and 3 migraine headaches this past week. She feels like her sessions have been helping her shoulder pain improve and has noticed a decrease in the frequency of the headaches. She would like another session similar to Monday's session.

O: There were increased muscular spasms in the right sub-occipital muscularture. The right levator scap was tight and tender. There was a large TP the size of a dime at the right lateral sub-occipital region. There was restriction in the left shoulder.

A: One hour upper body work with a concentration on the neck and bilateral shoulder complex regions. (45 mins supine.)

P: Client stated she felt "phenomenal" and re-scheduled for Saturday, October28, 2006.




As I said, the SOAP letters's come out on the program and since I like to know when the client is returning at a quick glance of the bottom of the file - this works best for me. Yes, I know it is not true SOAP charting, but it is how I like to do things for the massage clients.

You could easily just take lined paper and write a new chart note in a folder with one-six or even eight to a page, if you don't chart lengthy items. Just date - chart - sign and then do the same thing over again on the next visit under the previous one. When you fill up a page, move to a new one.


I like to chart in a way you understand what is going on with my client, and in a way that if I needed to provide info about this client to another person, I could do so somewhat easily. If you're taking chart notes for an insurance case, of course you'll need to be a LOT more specific than this.

But, this is a healthy sample of a quick note I'd write on a general client.




Now let's say it's a relaxation client. With my method which aren't exactly SOAP's as we mentioned, I'd do something like this:

S: Client presents today stating she has been very stressed this past week. Her work has been made up of long and tiring hours of sitting at the computer for payroll. He shoulders are "killing her". She stated she really needs to relax.

O: There were increased muscular spasms and tenderness in the neck, upper and lower back. The bilateral feet were sore.

A: One hour full body massage with an emphasis on relaxation.

P: Client stated she felt "glorious" and re-scheduled for next Wednesday (insert date).

 

[Pompal 09.]

Thanks for the replies. I definitely do chart after each session, I just didn't see the point in writing a novel for the clients who see me 1x or 2x per week. I have some better ideas to work with now. I would think anyone who sees me less often than every 2 weeks should get fresh SOAP notes.

 

[Crow T. Robot]

I see mostly clients who are a combo of relaxation & a chronic issue, just a few specific-treatment people. I use CARE notes rather than SOAPs now for most clients. First visit is a full-page sheet w/body views; subsequent visits are 4 to a sheet w/mini body views (front, back, sides). I note after every session, quick & easy. All soft-tissue abnormalities and changes are noted only on the body views - much quicker for me to read the little lines and Xs and triangles when I'm reviewing.

 

[ZoomN]

I was hoping someone would mention those. Thanks BJB-LMP!

Here's the thread that is an addition to this subject:

CARE notes

 

[Pompal 09.]

I think a thread called simplifing soap notes( or charting) is in order. I HATE soap notes! I have seen MT's who write a book after each session.

 

[hello.]

I do a couple of different things in my practice, but after each client, when I am doing my files for the day, (I use Excel daily to keep track of who I saw, money I made, etc.) and I have a comment line where I will put what was bothering them and what I found. And in the Customer Pro-File program, I just update that at the end of each month and I do more thorough SOAP notes there as there is a section just for that with a body map. Plus, I like having them in 2 places just in case something were to happen to one of the programs.