SOAP Notes for Massage Therapists – Flashcards

Unlock all answers in this set

Unlock answers
question
Subjective
answer
The 'S' in SOAP. What the client or the client's family or friend tells you. Based on the opinion, attitude or belief of the client. Listen for the client's 'why' they are seeking massage. Listening is the skill the therapist needs for gathering this information.
question
Objective
answer
The 'O' in SOAP. Information that the therapists feels or sees. For example, observing one shoulder higher than the other. Or palpating a tight muscle.
question
Asssessment
answer
The 'A' in SOAP. A place for Dr's to put a diagnosis. Or it can be for a therapist to put their treatment ideas before the session.
question
Plan
answer
The 'P' in SOAP. Can include techniques and methods used today, and for future sessions. Also include what at-home or self-care tips given to clients.
question
(PPALM) Purpose, Pain, Allergies, Lifestyle, Medications
answer
A verbal assessment you can ask your clients before the massage regarding the following: The purpose of the massage? Are they in any pain? Do they have any skin/scent allergies? What is their job or hobbies? Do they have any medical conditions, recent injuries/surgeries, or take medications that we need to know about before massage?
question
Documentation
answer
..The process of collecting, confirming and recording client information. Can be on paper or digital. Includes intake form, consent form and treatment plan. Must be signed and dated. Client records are legal evidence , and you decrease your risk by having proof of the info your client shares with you.
question
Scope of Practice
answer
activities, services and procedures that can be performed legally by members of a licensed profession. Important to know what is in, and what is outside of this.
question
Client Records
answer
In Louisiana law, they are to be maintained and stored for 5 years after the last date of service. Should be double locked. If the therapist is in private practice, or an independent contractor, they are maintained by the therapist.
question
Open-ended questions
answer
Questions you ask the client that allow the client to reflect and convey thoughts and feelings.
question
Close-ended questions
answer
Questions you ask the client that are direct and focused, client will frequently answer with yes or no.
question
Client Interview
answer
It helps you gather important information about the client, and it starts the process of building a trusting, therapeutic relationship. It is verbal, between you and the client. Eye contact, and listening are important components.
question
HIPAA
answer
outlines privacy standards for health care providers.....The Health Insurance Portability and Accountability Act. If a therapist removes client records from a building without proper authorization could be in violation of this.
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New