In a healthcare massage you perform the same assessments after the session that you performed before the massage session. If, for example, you conducted a posture and range of motion assessment before the session, you conduct a second posture and range of motion assessment after the session. This way you can document and compare the results of the two identical assessments to determine if your treatment improved the client’s condition. At the end of testing, summarize for the client your findings during assessments, your reasons for your treatment choices, and the results you observed. Ask the client to describe his or her experience and document their statements. For example, you might write, “the client reports that her headache pain decreased from moderate to mild-plus.”  The client can also give you valuable feedback about the locations where massage felt particularly needed and the techniques that felt especially effective. Review the client’s functional goals and discuss which aspects of the massage treatment felt like they were helping the client achieve goals. When you have discussed all the aspects of the session results that feel relevant, help the client take power in the healing process by providing some ideas for useful self-care activities he or she can use at home to increase the results from sessions.

<cb19-1> Concept Brief 19-1: Functional Outcomes Reporting

Client Self-Care

Chapter 12 introduced to self-care activities for clients. Recall that client self-care activities are actions the client performs that aid in recovering from an injury or in managing a condition or disease. You want to suggest self-care activities that are simple enough for the client to remember and easy enough to fit into a busy life. These activities may include:

• Hydrotherapy: Depending on the injury and its stage in the inflammatory process, you might suggest the use of ice packs; warm or hot packs; cool, warm, or hot baths; or Epson salt baths. For example, if the client has hypertonic muscles in the back and neck that contribute to headache pain, the application of a hot pack to the area in the evening, accompanied by gentle neck stretches, can be very helpful for loosening the area and improving muscle tissue health.
• Stretches: Static postural positions held during repetitive activities such as sitting hunched at a computer during work hours can exacerbate a client’s condition. Suggest one or two easy stretches the client might do to release muscle tension in specific areas throughout the day. For example, “Eduardo, three times during the work day, sit up straight in your chair and stretch your neck to each side by bringing your ear directly to your shoulder.”
• Self-Massage: Encourage clients to purchase massage bars or self-massaging tools to use daily to release muscle tension in target areas.
• Rest/Breaks: Clients who work at jobs that involve manual labor can be encouraged to take regular breaks or to take naps to decrease fatigue and relax the body.
• Referrals: Depending on the client’s condition, you might refer the client to another health professional such as a fitness trainer or physical therapist to help the client build strength in weakened muscles.

Record suggested self-care activities in the homework section listed under the P in many SOAP chart formats. At subsequent health interviews, follow up with self-care and document the activities the client is using to improve his or her health.