Profound transformations occur during our massage and bodywork sessions: a shift in perspective, a boost in self-confidence, relief from nagging pain, the ability to sleep through the night. We witness spirits coming alive and finding peace before our very eyes and beneath our hands.
The evolution is unmistakable, no matter how subtle the change. We can identify the progress—moderate increase in confidence and activity level, mild decrease in symptoms—in our clients’ retelling of their week: “I just knew I could unload the groceries from the trunk myself, so I didn’t call out for help,” “I was stretching after my 10 laps in the pool and felt so good I did another 10 laps,” “I walked all the way home from work and didn’t even notice the sharp pain in my knee.”
The evolution is unmistakable, no matter how subtle the change. We can identify the progress—moderate increase in confidence and activity level, mild decrease in symptoms—in our clients’ retelling of their week: “I just knew I could unload the groceries from the trunk myself, so I didn’t call out for help,” “I was stretching after my 10 laps in the pool and felt so good I did another 10 laps,” “I walked all the way home from work and didn’t even notice the sharp pain in my knee.”
We gleefully share our client’s victories with our confidants: our spouses, co-workers, and beaming mothers (maintaining anonymity, of course). Pen in hand, we easily record the events on paper to be recalled later when the client has a slight regression and looses perspective, the referring provider hesitates when writing the next prescription, or the insurance company is determining reasonable and necessary care.
Wait a minute. “Easily” record? Why is it such a struggle to keep written records of our sessions? Were we not taught to chart in school, or if we were, perhaps our teachers were not good role models in this area so we didn’t take it seriously? Did we learn to chart clients whose insurance demanded charts before reimbursement checks were cut, leaving us off the hook from charting the rest of our clientele? Did we get out of the habit once it no longer meant a better grade? Perhaps we were not provided enough choices in charting formats and lost faith in the benefits of charting. Even if we are practiced in charting, how do we choose which information is appropriate to record and which information could potentially cause problems later?
Clear and consistent written communication does not have to be complicated. It needs to flow naturally and become a part of the healing atmosphere and the tender care you provide your clientele. This task is easily incorporated if the benefits are evident with each return visit. Every word that is written, when reread before the next session, can teach you how to better understand clients’ needs and deliver a customized session that keeps them coming back. If you can accomplish this, you will have fewer problems keeping written, legal documents that benefit you, your clients, other healthcare team members, and your bottom line.
The theme of this feature is: keep it simple. Learn three levels of basic recordkeeping that build on gathering a brief health history sufficient to provide a safe and effective massage and bodywork session. First, understand the minimum information required for maintaining a medical record. Second, record information essential to tracking minor aches and pains. Finally, chart enough details to note changes in the client’s goals and health status. Sidebars will provide a deeper application of charting: writing case reports to communicate with other practitioners and researchers, communicating with insurance companies through functional outcomes reporting, and a CPT code update for insurance billing.
Intake Questions
Every client session begins with an interview: polite introductions and a few questions to assess safety and comfort. “Do you have any specific requests for today’s session?” “Is there anything I should know about you today to tailor this session to meet your needs and ensure your comfort?” “How would you like to feel when you leave here today?” These questions are not as blunt or impersonal as “Where does it hurt?” which is a conversation stopper when there is no presence of pain. Ask questions that invite a warm and caring relationship and collect details that help you design a session that makes the client feel heard and respected.
Whether verbal or written, an initial interview collects the following information:
Goals
What do they hope to accomplish in the session or series of sessions? Tailor your session to meet their needs.
Symptoms
Are they currently experiencing any pain or tenderness, stiffness, loss of function, swelling, numbness, or tingling? Ask them to prioritize their needs, honor their requests.
Health History
Are there previous injuries, surgeries or illnesses, and conditions currently cared for with a physician or by taking medications? Are there contraindications or cautions that require you to modify the treatment?
Medications and allergies
Find out what might interact negatively with your techniques, oils, or lotions to ensure a safe session.
Daily activities
What does a typical day look like with respect to work, home, and exercise routine? Are they modifying activities because of their conditions? This will help you suggest self-care in between sessions and is your best benchmark for progress.
Massage and bodywork history
Is this a new experience or are they veterans? Identify preferences and ensure a comfortable massage.
The Framework
These six areas provide enough information for ensuring a safe and productive massage for most clients. Intake forms vary depending on the environment. Spa intakes are typically brief and focus more on identifying allergies and heart conditions. On-site sports massage interviews may be verbal and recorded by the practitioner in a logbook and focus on identifying signs of shock and dehydration. A more thorough intake may be necessary when treating medical conditions such as cancer, Parkinson’s disease, or whiplash. There are more opportunities to influence healing or interact with medications, which warrants collecting more detailed information. Review a good pathology text and look up medications before an appointment with someone presenting with an unfamiliar condition, for instance A Massage Therapist’s Guide to Pathology by Ruth Werner (Lippincott Williams & Wilkins, 2005) and Massage Therapy and Medications: General Treatment Principles by Randal S. Persad (Curties Overzet, 2001).
Historical information does not need to be collected every session. Record the client’s answers to these questions at the first visit and revise annually thereafter. On a daily basis, ask for current information to shape the session: “Shall we continue to focus on your neck and shoulders, or is there something else I need to know about you today?” Updates are recorded on the daily record, not on the intake form, discussed below.
In a client file, fasten the intake form or health history to the inside front cover of the folder so it is visible each time the folder is opened. Annual updates are stapled over the previous form. Review the current intake before every session to keep the client’s goals for health in mind and create a safe and enjoyable experience.
Daily Recordkeeping
Massage and bodywork sessions employed for health maintenance and well-being often have a different look and feel than when used to treat specific medical conditions; so does the recordkeeping. Schools that teach charting typically focus only on the SOAP format (which was designed to address complex medical problems) and omit teaching the skills and benefits related to charting healthy clients. Once you master the most advanced application of charting, however, those skills are easy to modify for less complex tasks, such as recording how massage has influenced a client’s well-being.
Level One
Recording wellness sessions can be as simple as writing down the type of massage or bodywork techniques provided during the session. When the client is seeking a quiet respite from a crazy day and has no symptoms to speak of, simply record what you did and why, where you did it, and for how long. “Full body, relaxation massage, 60 minutes, no health conditions addressed” is a complete entry in a medical record.
The beauty of a simple, consistent, recordkeeping system is that any unusual information stands out. If the client mentions a headache on the rare occasion, you have a system that will track how often those headaches occur and the activity that could be contributing to the occurrence. Clients often visit us more frequently than their medical doctor and spend more time during each appointment letting us in on their subtle aches and pains, thoughts and feelings. During the course of our relationship with them, we are presented with multiple opportunities to influence their health and well-being. We need to take our responsibilities seriously by keeping a record of our sessions.
Level Two
The next level of recordkeeping is to write down information clients share before they get on the table, such as, “I cannot seem to rotate my right wrist as much as I can my left when doing bench curls at the gym,” or “It is getting harder and harder to turn my head to the right when backing out of the drive.” Typically clients mention a symptom (stiffness) and associate it with an activity (exercise, driving). Both are critical pieces of information. If we only record “stiff wrist” we loose the opportunity to ground the detail in an everyday activity and therefore miss the chance to quantify progress or to ask an appropriate follow-up question.
Two critical pieces of information are best recorded together: 1) how clients feel, and 2) what clients are doing when they notice how they feel.
Experiencing pain, by itself, is not enough information to be helpful. If you write “pain in neck” every session, the ability to note change or progress is lost. Knowing when it hurts and when it doesn’t hurt, and how much clients have to modify what they are doing because of how much it hurts speaks volumes.
For example, Mari mentioned her knee was bothering her. She started noticing it every time she climbed stairs. She thought it was a new issue and was wondering what had triggered this. In looking back at her records, she had this same knee problem earlier this spring and again last fall. We were able to do a little exploring into her recent activities and discovered that Mari had made several trips up and down the attic ladder to bring the winter clothes down and take the summer clothes up to storage. Together we uncovered a possible link to this reoccurring problem. Mari might even be able to avoid a reoccurrence next year by enlisting some help when changing out her wardrobe. Tracking client’s minor aches and pains and the activities that trigger them can help them identify patterns or behaviors and make needed adjustments. Maintaining perspective of clients’ conditions also helps keep them cognizant of their progress.
Level Three
The next level of basic recordkeeping is to assess the severity of any symptoms clients mention by considering how much it affects their activities. When clients are basically healthy, there is not much to report beyond the treatment provided. However, whenever clients say they feel stiff or tender or tired, write it down and place it in a measurable context. This can be as simple as describing how an activity is affected by the symptom or assigning a number between zero and 10, with 10 representing disabled or bedridden. If there is no change in activity, the symptom is considered mild or can be rated a 1, 2, or 3, out of 10. If symptoms cause a client to modify one or more daily activities, such as fewer trips to the gym or lighter loads of groceries from the car, the symptom is moderate or is rated a four, five, or six, out of 10. If the client is unable to perform some activities, such as run, ski, or lift weights, the condition is severe and can be rated seven, eight, or nine, out of 10. The more activities affected by the symptom, the higher the number between zero and 10.
Completing the Task
In summary, the following should be recorded on a wellness chart.
• Goals for the session. Why are they there and how would they like to feel upon leaving?
• Symptoms. Do they have any tenderness or pain, stiffness, numbness, or is there anything they would like to improve on? Rate the symptom on a scale of 0–10.
• Activities of Daily Living. Are there activities impacted by how they feel, such as their ability to sleep, work, exercise, or do household chores? Are they limiting their activities or changing how they would normally perform the activity to avoid the pain? Specify what they are able to do in relation to their previous ability.
• Treatment. What you did (deep-tissue massage). Why (to relieve tight trapezoids and pectoral muscles). Where you did it (full body, focus on neck, chest, and shoulders). Duration (60 minutes).
Once a symptom has been measured, progress can be easily noted. Change happens slowly sometimes, sometimes quickly, but rarely does it happen instantaneously and permanently. Someone with pain in the low back that prevents them from lifting their grandchild often goes through various stages of healing, setbacks, and transformations that deserve to be recorded. Without recording the level of severity, all we can surmise is that the pain is present until it is completely gone. We should always be able to identify detailed progress. It is quite remarkable to be able to state that the client’s pain is now a three out of 10 from a six out of 10 and the client can lift that five-year-old grandchild into the highchair, but has a new goal of lifting the child and bending over to put the child into the car seat. This is a motivating story of progress, deserving of additional sessions to help them reach their new goal.
Diana L. Thompson is a licensed massage practitioner, educator, and author of Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists, third edition. She is president of the Massage Therapy Foundation, which provides research grants for massage and bodywork to help advance the profession and helps fund community service projects that bring massage therapy to people in need. Contact her at soapsage@comcast.net.