The initial health care session interview can be fairly complex and involve much physical assessment (e.g., posture, gait, range of motion, palpation). As with the wellness session described in detail in Chapter 10 you are likely to begin with a review of policies and procedures, a discussion of the client’s general medical information to rule out contraindications to massage, and a review of the informed consent form. If the client’s condition causes pain, it is useful to ask the client also to fill in a pain questionnaire (discussed in Topic 19-2).

In all cases, gather and record in-depth information on the client’s symptoms, location, severity of the symptom, occurrence, onset, and exacerbating or relieving activities. This process was described in depth in Chapter 12, Topic 12-4 (Introduction to Documentation).  In a health care session you are more likely working with a client who has suffered an injury (e.g., car accident, sports injury, repetitive stress injury) or has a diagnosed condition (e.g., fibromyalgia, rheumatoid arthritis, cancer, anxiety disorders, etc). You may have a prescription from the client’s physician to provide massage, or a referral from another health care professional. These members of the client’s health care team may specify some of the treatment goals for massage. For example, a client may be sent to a massage therapist specifically to decrease muscle tension in the hamstrings, erector spinae muscles, and psoas muscles. This will be stated on the client’s prescription from the treating physician. In any case, you want to discuss and record the client’s functional limitations and work with the client to list functional goals. If the client’s needs seem broader than the prescription you may need to discuss the case with the physician with the clients consent.

Functional Outcomes Reporting

Functional outcomes reporting is a form of writing SOAP or chart notes that focus on the client’s ability to function in activities of daily life. As the therapist, you document the client’s functional limitations and work with the client to develop meaningful functional goals. Treatment focuses on helping clients reach their functional goals so that they can complete necessary activities without increased symptoms and participate in activities of value to them.

Functional Limitations

Functional limitations are defined as any restriction or impairment of basic functions. Basic functions include seeing, hearing, speaking, walking, standing, sitting, carrying, lifting, walking up stairs, moving the arms, legs, trunk, or head, or grasping and holding objects. Functional limitations impact a client’s ability to participate in activities of daily living. Primary activities of daily living include getting around inside the home, getting in and out of bed, bathing, dressing, eating, getting a full night’s sleep, and going to the toilet. People must also be able to keep their homes clean, get around outside the home, use the telephone, pay bills, shop for food, prepare food, care for children, drive cars, and perform employment tasks. People participate in additional activities that hold meaning and value in their lives. They may take walks with friends, garden, ride bikes, dance, take yoga classes, go to movies, paint, and any number of other activities where they bond with friends and family members and participate in the larger community.

An injury or pathology that causes functional limitations that restrict a person’s ability to participate in activities of daily life can impact a person on many levels. Physically, the person can’t do what they once were able to do. This can make them feel weakened emotionally, which can influence their mental patterns. If they can’t get out and connect with people normally, they may feel spiritually inhibited, lonely, and isolated. Limitations can range from minimal but annoying to completely debilitating, and it can sometimes be hard for others to truly understand and empathize with someone else’s feelings about a physical restriction. For example, after a fall while cycling, Steve finds he can’t run more than five miles without knee pain. At six miles the pain increases to a moderate-minus pain and at eight miles the pain increases to a moderate-plus pain. At ten miles he has to stop running. To most people this individual seems highly functional, but Steve is a marathon runner, and these limitations seriously impact his ability to participate normally and fully in his life.

When therapists focus on comprehending a client’s functional limitations and how these limitations impact the client’s activities of daily life, they are better able to provide guidance to clients in the goal setting process.

Functional Goals

Functional goals are written before the session goals to define the particular activities the client would most like to accomplish in daily life without a significant increase in symptoms. Review the information the client provides in the S section of the SOAP chart, particularly the section where the client describes activities that aggravate the condition. Aggravating activities tend to be related to work or life duties such as driving to work, sitting at a computer, or caring for children. Often these activities are ones that clients must participate in to maintain some normalcy in life. You should also question clients about activities that have recreational or social value and add to life’s meaning. Ask the client to prioritize two or three activities that are particularly important. Set goals involving these activities.

In many different types of goal-setting the acronym SMART is used as a reminder to write useful goals that lead to reliable outcomes. In functional goal setting keep these factors in mind when writing goals:

• Specific: The goal should relate directly to an activity of daily life and be as specific as possible. For example, “housework” is broad, but “vacuuming the floor twice a week” is more specific. “Child care” is broad, but “lifting a child in and out of a car seat” is specific.
• Measurable: Goals must be quantified and qualified in order to demonstrate progress. To quantify the goal, describe how much of the activity should be performable. For example, “lift 5 lbs onto a conveyer belt for one hour three times during the day,” or “run three miles,” or “lift 30 lb toddler in and out of a car seat twice a day,” etc. To qualify the goal, describe what the client should feel like at the completion of the activity. For example, “with no increase in pain,” or “with mild increase in pain,” or “with no noticeable increase in muscle tension,” or “with mild stiffness and soreness.”
• Attainable: Guide the client towards setting goals that are realistic in relationship to the client’s current condition. If the client experiences increased pain from moderate-plus to severe when driving 2 miles daily to work, it is unrealistic for the client to expect that they will have no pain with driving to work in a short time frame. A more attainable goal would be “to drive 2 miles daily to work with a smaller increase in pain from mild to moderate in two weeks; in three weeks drive 2 miles daily to work with moderate-minus pain.”
• Relevant: The goal should feel relevant and meaningful to the client so that they feel motivated to participate in their own health care through self-care activities and make a commitment to massage treatment.
• Time-bound: Help the client set both long- and short-term goals. Long-term goals are commonly reached within 30-60 days, while short-term goals are written for a 7- to 14-day time frame. You always want the goal to be as specific as possible. For example, “run 3 miles with moderate-minus knee pain in 12 days” rather than “run 3 miles with moderate-minus knee pain in about 3 to 4 weeks.”

When the client has determined one to three functional goals with your help, write the goals down in the A section of the SOAP chart. Write both a short-term and long-term goal for the same functional limitation. When the client reaches a particular goal, it is documented as a functional outcome of treatment. Figure 19-4 shows a SOAP chart with functional goals and the functional outcome the client has already achieved.

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