SOAP notes help!

[y4hoo000019]

If the client describes ailments in the medical history, but these ailments are not pertinent to the goal of that particular treatment massage, do those details still need to be documented under S? For example, if the client states that he or she has rheumatoid arthritis in her fingers and knees, but her goal is to relieve her shoulder pain, do I need to detail the rheumatoid arthritis under S in the chart?

-Mimi

 

[Chef]

Personally I would.
I document everything they tell me.
Also what you drag out of them, quite a few people don't tell you everything then you notice the nice scar on their back and question them on it and get the " oh yeah I had back surgery a few years ago". I would rather have as much info written down as possible than just a little bit on em.

 

[Elii [ucansuckkit]]

I agree with Shannon. You never know when that RA client will come back and not remind you about the RA, or not tell the next therapist because they believe it is already charted.

 

[Staggerlee]

I totally agree: whatever your client tells you (and what you can see, too) should be recorded in SOAP notes. In reading a few articles, if you don't record it, it didn't happen (and you can't CYA in case your notes are taken into court - not that it would ever happen).

I'm for more not less.

 

[Chi Jackson]

Yep... agreed.... document it all. You can really never have too much on a medical history.

History is everything!