What client health records do I need for Thai massage?

Medical documentation now serves multiple needs, and, as a result, medical notes have expanded in length and breadth compared to fifty years ago. Medical notes have evolved into electronic documentation to accommodate these needs. However, an unintended consequence of electronic documentation is the ability to efficiently incorporate large volumes of data.

These data-filled notes risk burdening a busy practitioner if the data is not helpful. As significantly, inaccurate information may harm the client. Making the most clinically relevant data in the medical record easier to find and more immediately available is essential.

A SOAP note is a way for you to document the details of your client assessment, current treatment and ongoing treatment plan in a structured and organized manner. The four parts of a SOAP note are the same as its abbreviation.

• Subjective – What the client tells you
• Objective – What you see during the treatment
• Assessment – What you think is going on
• Plan – What you will do about it

A SOAP note’s advantage is organizing this information in an easy-to-find format. The more concise yet thorough a SOAP note is, the easier it is for practitioners to follow. The structure of a SOAP note reminds you of specific tasks and provides a framework for evaluating information and a cognitive framework for clinical reasoning. And since many other health professionals utilize SOAP notes, they are an excellent way to communicate with practitioners in other health disciplines.

This section refers to information the client verbally expresses before or during treatment. Use this section to record the subjective experiences, personal views or feelings of your client, and be sure to include the following:

i.e. Right shoulder hurts when they raise the arm sideways

What does the client say is the CC? The CC is like the title of an essay and should hint toward the remainder of the note. The CC can be a physical symptom or condition, a previous diagnosis or another short statement that describes why the client is visiting you for a Thai massage. 

Be aware that clients may have multiple CCs and that what they list as their CC may not be the primary CC. Have your clients list their problems and pay attention to discover the most compelling issue. An effective diagnosis will only occur if you can identify the main problem.

i.e. A 36-year-old male with shoulder pain.

The HPI begins with a simple one-line opening statement, including the client’s age, sex and reason for the visit, and then elaborates on the client’s CC. Focus more on the quality and clarity of your notes and less on excessive detail. An acronym often used to organize the HPI is termed OLDCARTS:

• Onset: When did the CC begin?
• Location: Where is the CC located?
• Duration: For how long has the CC been going on?
• Characterization: How does the client describe the CC?
• Alleviating and Aggravating Factors: What makes the CC better and worse?
• Radiation: Does the CC move or stay in one location?
• Temporal aspect: Is the CC worse (or better) at a particular time of the day?
• Severity: Using a scale of 1 to 10, 1 being the least, ten being the worst, how does the client rate the CC?

• Medical history: Pertinent current or past medical conditions
• Surgical history: Try to include the year of the surgery and surgeon if possible.
• Family history: Include pertinent family history. Avoid documenting the medical history of every person in the client’s family.
• Social History: Use the acronym HEADSS, which stands for Home and Environment; Education, Employment, Eating; Activities; Drugs; Sexuality; and Suicide/Depression.

The ROS is a system-based list of questions that help uncover symptoms the client does not mention. Examples include:

• General: Weight loss, decreased appetite
• Gastrointestinal: Abdominal pain, hematochezia
• Musculoskeletal: Toe pain, reduced range of motion in the right shoulder

You may list current medications and allergies under the Subjective or Objective sections. However, it is essential to include the medication name, dose, route, and how often the client takes any medication.

i.e. Motrin 600 mg orally every 4 to 6 hours for five days

This section consists of observations that you make of the client. A common mistake is not differentiating between symptoms and signs. Symptoms are the client’s subjective description that you record under the subjective heading, and a sign is an objective finding that relates to the symptom reported by the client.

i.e. Acute tenderness at the back of the shoulder joint when pressed. Pain only begins when the arm moves in abduction past the shoulder’s height.

In this section, you record your client’s diagnosis based on Subjective and Objective evidence. Elements include the following:

List the problem list in order of importance. A problem is often known as a diagnosis.

List the possible diagnoses, from most to least likely, and the thought process behind this list. You should also include any possible diagnoses that may harm the client, even if they are less likely.

i.e. Problem 1, Differential Diagnoses, Discussion, Plan for Problem 1 (described in the plan below). Repeat for additional problems.

This section details the need for additional treatments and consultation with other health practitioners to address the client’s illnesses. It also addresses any additional steps you plan to take to treat the client. For each problem:

A comprehensive SOAP note must consider and accurately assess all subjective and objective information to create the client-specific assessment and plan.