MM Chapter 12: Wellness Massage

In the simplest wellness chart, the therapist’s name appears at the top, followed by the client’s name, DOB, and medications (Fig. 12-9). The area under TX (treatment) is used to describe the techniques used and any adaptations made to ensure the client’s comfort and safety. The C (comments) section is for recording the client’s preferences […]

SOAP stands for subjective, objective, assessment, and plan. This refers to the types of information you record in each section of a SOAP chart. While there are many types of documentation systems, SOAP charting is a standard format used by physicians, physical therapists, chiropractors, nurses, and other professional healthcare providers, so is a good system

Both objection data (i.e. signs) and subjective data (i.e. symptoms) should be both quantified and qualified in the charting process. Quantifying Data The symptoms a client reports (subjective information) and the signs a therapist observes or palpates (objective information) should always be quantified so that progress or a lack of progress can be recognized and

Abbreviations are used in written communication, such as SOAP charting, and by healthcare providers or the public during verbal communication. For example, people regularly say AIDS and MS rather than acquired immune deficiency syndrome or multiple sclerosis. Abbreviations for words or phrases take up less space on the page and allow the therapist to write

When documenting any session, these basic guidelines are important: Write clearly and fill in all areas of the form with information. If an area is not applicable (unlikely), write NA in the space. This ensures that the document could not easily have been altered in the event it becomes part of a legal proceeding. Never

Professional massage therapists use consistent charting practices to promote client safety, establish the therapeutic relationship, organize assessment data, keep accurate historical records, demonstrate progress, communicate with a healthcare team, and for liability reasons. Safety Documentation forms are used not only to rule out contraindications but also to provide a record of the client’s reaction to

After ruling out contraindications, session planning focuses on using data gathered before, during, and after the session to meet the client’s unique wellness goals. Using Data Gathered BEFORE the Session for a Customized Wellness Massage During the health intake interview, you make general observations about the client’s freedom of movement, symmetry, breathing patterns, stress level,

Structure your palpation practices carefully to develop good skills and make efficient use of time. The more systematic you are now in assessing the client’s tissue and gathering data, the easier it will be for you to shift into assessment when doing a healthcare massage. A systematic approach to palpation also ensures that you will

All highly skilled massage therapists palpate continuously, on an almost subconscious level, gathering, interpreting, and responding to data received through their fingers, palms, knuckles, forearms, and elbows. This intense process allows for making moment-by-moment adjustments in the pressure and speed of the stroke to best create positive changes in soft tissue or note changes that

Different types of massage sessions require different levels of palpation, but good massage therapists palpate attentively and continuously throughout all sessions. In a wellness session, the general objective is to palpate in order to adjust techniques appropriately during the massage. For example, you wouldn’t want to plow through bound-up tissue as this could cause the