treatment plans for clients

[Mexxia]

Does anyone write treatment plans for your clients?  How do you go about doing this?  We learned nothing about writing treatment plans in school.  Thank you!

 

[LuvThosePurpleShoes]

Hi Tiffany,If the client is coming for clinical issues I will write SOAP notes for each visit.  The first SOAP note includes an overall plan in the P (plan) section.  During subsequent sessions, I state the plan for the next visit as it relates to the overall treatment plan.  If you are not familiar with the SOAP note format, it goes something like this:S (Subjective findings - What the client says she/he feels) - The client states that she has pain in her right shoulder which seemed to start after raking leaves one week ago.  She reviews visiting Dr......for chiropractic treatment, and that he suggested therapeutic massage for muscle spasm and pain.  When asked exactly where she feels the pain, she pointed to her right scapula and stated that the pain seemed to travel into the back of her arm and somewhat up her neck.O (Objective findings - Just the facts - What you observe in palpation, measurements and testing) - Upon observation of the torso and upper body, the right shouder appeared higher than the left and anteriorly rotated.  When asked if she had any pain with movement, she abducted her arm 90 degrees and reviewed that she could not raise it any higher without pain.  When asked where she felt the pain she pointed to the axillary region of the right shoulder.  Palpation revealed a trigger point in the right infraspinatus which referred into the anterior shoulder and down the right tricep.  I also found spasm in the right teres minor and latissimus dorsi (axillary attachment) and corresponding tension in the torso and low back on the right.  Crepitus and discomfort (reviewed 7/10) was found in the right upper trapezius, levator scapula and rhomboids.A (Assessment - What you did and how it worked) Trigger point therapy was applied to the right infraspinatus with some reviewed decrease in referral intensity.  Spasm was relieved in the teres minor and latissimus dorsi by applying direct compression to these muscles.  Administered Swedish and deep tissue techniques to the upper trapezius, rhomboids and levator scapula on the right as well as to the corresponding muscles on the left.  After the session, the client reviewed a 75% reduction in right shoulder discomfort.  She was able to abduct her right arm to approximately 120 degrees before feeling discomfort in the shoulder.  The right shoulder appeared to be level with the left, but still more anteriorly rotated.P (Plan - long term and short term)  Longterm Plan: to relieve overall muscle pain and tension in the right shoulder, increase the range of motion to 180 degrees of abduction,  and rebalance the structure of the right shoulder so that it is more level with the left and less anteriorly rotated.Short term Plan:  Next visit address the same muscles as were addressed in the first visit and investigate the anterior shoulder muscles and their relationship to the client's stated pain pattern.There is some controversy about what should go in O & A categories of a SOAP note, but this is how I would do it on an initial evaluation.  Sorry this is such a long message.  I hope it helps.best of luck,Cassandra

 

[christav.rodriguez]

treatment plans for clients

I have a book called Outcome Based Massage by Carla-Krystin Andrade and Paul Clifford that has some good chapters on client examination/treatment planning.

http://www.amazon.com/exec/obidos/tg/detail/-/0781717434/qid=1123208753/sr=8-1/ref=pd_bbs_1/002-6598725-9392814?v=glance&s=books&n=507846

Some of it seems over my head as a 525 hr massage school graduate, but worth using as a reference.  But it does give good instruction for the touch therapist to evaluate and create a treatment plan.

 

[Girl Stewie]

treatment plans for clients

I do SOAPs regularly. Typically what I do is discuss the approach briefly with the client; areas to work, areas of concentration and if there are any techniques that might be specific to a problem area; then do the treatment and write a description of what I did after.I like the freedom of working without a specific program. It allows me to alter what I'm doing to meet any unexpected needs that I encounter while I'm there, and allows me to vary my treatment so that I don't get bored.

 

[Pompal 09.]

treatment plans for clients

...in addition, if you're working in relation to a group approach (i.e., attending physician, chiro, PT), you may have prescribed areas/protocols to follow.Like merlescuz, I tend to have an overall approach that will probably change from session to session even when dealing with the same problem area/concern.But it's always a good idea to keep SOAP notes. Never know when they're gonna come in handy.