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August 24, 2007

Success Is In The Details (Part 4): Client Notes

Client notes consist of an intake form, a method for tracking progress and treatment of a client's condition, and keeping up with clients massage consumption trends, likes and dislikes, and client promotions and incentives. In fact, lack of client notes can get you in trouble. Without them you could be accused of malpractice. And keeping up with them can be a headache. Being without them could create a bigger headache if your notes are called into court for automobile accidents and workman's compensation claims. So keep up with them because you never know when you'll need them.

I decided to make my practice more clinic-based rather than relaxation. This means that when I created my intake form, I had to make it more thorough than name and address and hobbies. I patterned my intake form on a sample that was provided in my Pathology A to Z: A Handbook for Massage Therapists textbook. Sometimes I find myself apologizing for the complexity of my intake form, especially if my client is there for just a relaxation massage. The other downside to an intricate intake form is time management. If a client arrives for the first time right at the time the appointment starts, it may take them longer to fill out an intricate intake form, especially if they have an involved medical history. I usually suggest that folks arrive about ten minutes early for their first appointment.

The notes you take about a given client's massage may be some of the most important paperwork you have. If you have a relaxation practice, your note taking can be greatly simplified. However with a more clinical practice, notes become more complex. Admittedly, this is probably the most challenging part of my behind the scenes practice. SOAP notes help track a client's condition with assessment, treatment plan, and outcome. Some massage schools do a better job of teaching charting than others and mine did almost none. What they did teach us did not help to simplify the process. If you have a serious clinical practice, it would pay you to take a continuing education class on charting.

By talking with my peers, few were reluctant to share their charting practices with me and many do no charting at all. One of the quickest charting templates I saw was for a relaxation practice that the therapist developed themselves. Since they worked within a predictable flow, they set up an index card with a list of body parts across the top. When they worked a given area they put a check under the body part. With a line off to the side to record the date, it took only seconds to keep up with their notes, something they could do while their clients were getting dressed.

I like to offer my clients incentives for repeat business. For every ten massages they get their 11th one for free. They get a postcard in the mail that they can bring back to me to redeem the offer. I also send out birthday postcards that offer a one-time discount on a massage during their birthday month. How do I keep up with this? I use a computer program called Act 2000 that lets me keep an electronic client database. This is the second most challenging aspect of my paperwork. Because my office is an "old-school" paper-based office, bringing a computer into the mix is clunky. Also, the program is not ideal for charting because it allows for only the most succinct notes. My fantasy has always been to buy the Massage Office or Massage Soft software that would allow the therapist to create a client file and chart the session by using a coloring wand on a picture of the body. With the push of a button, it even fills in insurance forms and let's you print them out or (I'm guessing) e-mail the claim form directly to the insurance company. Unfortunately, I could never justify the expense since I don't file insurance and I don't have an on-line connection at my office.

Any suggestions that my readers have for making paperwork easier for the massage therapist would be greatly appreciated. Send your ideas and I'll send a gift to the best suggestion and share them with my readers.

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Posted by linda at August 24, 2007 7:11 AM

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