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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5521_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 6 / Communication and Documentation 281
( common ones in bold) continued
TERM SYMBOL
up, increase
with w/, cˉ
without w/o
Anatomy
abdominals abs
anterior superior iliac spine ASIS
biceps brachii bi
cervical, cervical vertebrae C, C1–C7
connective tissue CT
cranium Cr
deltoid delt
diaphragm dia
energy E
erector spinae ES
gastrocnemius gastroc
↑
TERM SYMBOL
quadriceps femoris quads
rhomboid muscles rhomb
scalene muscles scal
sternocleidomastoid SCM
sacroiliac SI
soft tissue ST
thoracic, thoracic vertebrae T, T1–T12
tensor fascia latae TFL
temporomandibular joint TMJ
trapezius muscles traps
triceps brachii tri
Medical Record Terminology, Measurements
as needed prn
beats per minute bpm
complains of c/o
gluteal muscles gluts,
glutes
hamstrings hams
head and neck H&N
iliotibial band ITB, IT
band
latissimus dorsi lats
levator scapulae lev scap
low back LB
lumbar, lumbar vertebrae L, L1–L5
muscles mm
occiput occ
pectoralis muscles pecs
posterior superior iliac spine PSIS
quadratus lumborum QL
continue same CSTx
could not test CNT
date of injury DOI
did not test DNT
full body FB
full-body relaxation massage FBRM
history Hx
long-term goal LTG
medications meds
next visit nv
prescriptions Rx
recommendation rec
same as S/A
same treatment SATx
treatment Tx
continues on following page
282 INTRODUCTION TO MASSAGE THERAPY
( common ones in bold) continued
TERM SYMBOL
Symptoms, Maladies
adhesion adh
backache BA
chronic fatigue syndrome CFS
diagnosis Dx
edema ed
fibromyalgia syndrome FM, FMS
fibrous tissue FT
headache HA
pain P, P
sleep disturbance SD
symptoms Sx
tender point TeP
tension tens
trigger point TP, TrP
Directional, Descriptive Terms
anterior ant
bilateral, both BL, B
TERM SYMBOL
posterior post
prone pr
proximal prox
right ®
severe sev
side-lying SL
superior, supine sup
within normal limits WNL
Actions
abduction abd
adduction add
circumduction circ
depression dep
dorsiflexion DF
elevation ele
eversion ever
extension ext
flexion flex
inversion inv
constant const
excessive xs
external ext
internal int
lateral lat
left L
light, low, mild L
medial med
moderate mod
normal N
lateral flexion lat flex
opposition opp
plantarflexion PF
pronation pro
range of motion
active range of motion
active assisted range of motion
passive range of motion
resisted range of motion
rotation rot
side-bending SB
supination sup
ROM
AROM
AAROM
PROM
RROM
Chapter 6 / Communication and Documentation 283
and symbols for massage treatment records, identifying
the more common ones.) Some of the more helpful symbols you may use include delta ( ⌬ ), the standard symbol for
change, or an arrow (→) to indicate posttreatment assessment findings. The changes you indicate will typically be
positive changes due to treatment, but if symptoms worsen,
you can still use these symbols. For instance:
• Full-body relaxation massage resulted in reduced
pain and increased left lateral flexion of the neck:
• FBRM → ↓P ⫹ ↑(L)lat flex neck
• The client complains of moderate pain in the right
shoulder:
• Cl c/o mod P (R)shoulder
• The left anterior superior iliac spine was higher than
the right before the massage, but they were even
after the massage:
• (L)ASIS ↑ ⌬ (L)ASIS ⫽ (R)ASIS
Typically, not much time is available to fill out a SOAP
note, so you may be inclined to wait until the end of the
day to document all the SOAP notes. The longer you wait to
fill out the SOAP, however, the less accurate your documentation will be, especially if you have to fill out numerous
SOAP notes at one time. After several different clients have
come and gone, it is often difficult to remember details
specific to each client. Information is more accurate when
you document immediately after the session. Because these
documents are used as the basis for future treatments and
may also be used by other healthcare professionals as well as
attorneys and insurance companies, your accuracy is critical.
Using appropriate abbreviations can speed up the process
of documentation, allowing you to fill out the SOAP note
immediately after each massage session.
SOAP Note Variations
All of the previous examples of SOAP notes are full-page
forms that provide space for recording the pertinent details
for therapeutic massage sessions. There are a number of
variations available. A shortened form can be used when
a client is treated for general concerns or given a wellness
massage. One of the shortened forms is called the Wellness
Chart (Fig.6-5). Tx refers to treatment, in which you document general information on treatment and results. C refers
to comments, including brief recommendations for another
treatment and self-care. The form shown here includes a
body diagram for you to note specific data.
Case Studies
Introducing . . . The Case Studies
Three different case studies are presented throughout
this text. The participants are introduced with brief
biographies followed by the documentation forms used to
record their information: health history and SOAP notes.
The SOAP note will be highlighted differently in each
chapter that includes the Case Studies, showcasing the
information that is most appropriate for those chapters.
Here, we introduce Rob Blackwell, Timothy Roberts, and
Kirsten Van Marter.
Progressive Case Study 1:
Rob Blackwell
Rob Blackwell is a
42-year-old man who is
trying massage for the first
time and hopes to restore
his sleep and reduce pain
in his neck, shoulder,
back, and knees so he can
lift weights and golf as
he used to. Rob says his
shoulder pain interferes
with his activities the most. He complains that his
sleep is affected by his pain, and his health history
reveals osteoarthritis and tendinitis in his knees,
multiple sprains in his ankles, sinus trouble, and
multiple head injuries. Your interview determines that
the osteoarthritis diagnosis was made more than 10
years ago. On a pain scale of 1 to 10, with 10 being
the worst pain, Rob says all of his areas of concern
are about 4. He soaks in the hot tub, which helps the
pain, and he occasionally takes ibuprofen, which could
affect his pain perception during massage. All of the
information Rob tells you is subjective information,
and you record anything that is pertinent to his chief
complaints (Figs.6-6 and 6-7).
The massage for Rob is designed to reduce pain
and tension and find fascial adhesions, but you focus
on the condition of the soft tissues in his shoulders.
You use your standard massage flow, with the addition
of some therapeutic techniques. After the massage,
you perform the posttreatment assessment, prioritize
Rob’s functional limitations, and determine short- and
long-term treatment goals. You make treatment plan
recommendations regarding future treatment, self-care,
and referrals to other healthcare practitioners.
284 INTRODUCTION TO MASSAGE THERAPY
Progressive Case Study 2:
Timothy Roberts
Timothy Roberts is an
elderly gentleman who
is primarily interested
in relaxation. A person
his age is considered
part of the senior
( geriatric) population,
but treatment should
be based on the
condition of the soft
tissues and general
state of health. He
indicates no specific
areas of concern or
chief complaints, but you notice that he takes blood
pressure medication and has a history of skin cancer
(Fig. 6-8).
The main focus of Timothy’s massage will be
relaxation and circulatory enhancement. During
the massage, you find fascial restrictions and
reduced passive ROM in his left ankle. Following
the massage, you briefly discuss plans for future
massage treatment and self-care activities.
Progressive Case Study 3:
Kirsten Van Marter
Kirsten Van Marter is a 38-year-old woman in her
third trimester of pregnancy. She has received
monthly massage treatments in the past but is a
first-time client for
you. Her primary
complaint is mild
but constant back
pain. Her secondary
concern is mild
pain in her hips,
pelvis, neck, and
shoulders. She is
looking for pain
relief in her areas
of concern as well
as restored sleep,
restored normal fitness level, and she wants to be
able to pick up her child without pain. She says
that she worries that she will drop her daughter
because of the pain. She is physically active and
in good health, except for anemia and gestational
diabetes during this pregnancy. You record any
information Kirsten shares with you that is pertinent
to her areas of concern as subjective information
(Figs.6-9 and 6-10).
There are a number of techniques and
areas to avoid for prenatal massage and special
considerations to make. You keep Kirsten in
the side-lying position for most of the massage
and provide a relaxation massage with some
therapeutic techniques. After the massage, you
perform a posttreatment assessment, prioritize her
functional limitations, and determine short- and
long-term treatment goals. You make specific
recommendations for future treatment and self-care.
The language of massage therapy contains many medical
and scientific terms. To learn this language, you need commitment and lots of practice. Use your eyes, ear, mouth, and
body in the process to reinforce and facilitate learning, but
make sure you are learning correctly. In all modes of communication, whether oral or written, with the client or another
healthcare professional, you must use correct spelling, pronunciation, and context. Knowing how to break down a word
to determine its meaning will help you understand the universal language of healthcare and may make it easier to learn the
basics of anatomy, physiology, pathology, and pharmacology.
Based on the events in the history of massage and the
concepts of ethics and professionalism, you can see why
effective communication and documentation are important. Without effective communication, you cannot gather
appropriate and important information or accurately document activity that occurred. Inaccurate records provide an
undependable history, they can lead to misunderstanding,
and they can compromise your integrity and professionalism. Ethics and professionalism are cornerstones for a
successful practice. Your understanding of medical terminology, anatomy, and physiology help you read and
write useful massage treatment records that contain helpful information for you and the other members of your
clients’ healthcare team.
Gathering information through effective communication with clients is vital to good documentation. Establishing
rapport and mutual trust and validating the client’s condition and perceptions are necessary for creating a clientcentered focus for safe and effective massage treatment.
Effective communication, reflective listening skills, asking
useful questions, and considering nonverbal communication
all help make the interview more effective and lead to the
most thorough picture of a client’s current condition. This
information is recorded on a SOAP chart or other documentation format. Documentation is essential for the safe and
effective treatment of clients as well as for communication
with other healthcare providers.
Chapter 6 / Communication and Documentation
285
Figure 6-5. Wellness chart. (Reprinted with permission from Thompson DL. Hands Heal: Communication,
Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Baltimore: Lippincott Williams & Wilkins,
2006.)
286 INTRODUCTION TO MASSAGE THERAPY
Figure 6-6. Health Information Form for Rob Blackwell. (Reprinted with permission from Thompson DL. Hands Heal:
Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Baltimore: Lippincott Williams &
Wilkins, 2006.)
Chapter 6 / Communication and Documentation
287
Figure 6-6. (continued )
288 INTRODUCTION TO MASSAGE THERAPY
Figure 6-7. SOAP Chart for Rob Blackwell, subjective information highlighted. (Reprinted with permission from
Thompson DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed.
Baltimore: Lippincott Williams & Wilkins, 2006.)
Chapter 6 / Communication and Documentation
289
Figure 6-8. Wellness chart for Timothy Roberts, subjective information highlighted. (Modified with permission
from Thompson DL. Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists.
3rd ed. Baltimore: Lippincott Williams & Wilkins, 2006.)
290 INTRODUCTION TO MASSAGE THERAPY
Figure 6-9. Health Information Form for Kirsten Van Marter. (Modified with permission from Thompson DL. Hands Heal:
Communication, Documentation, and Insurance Billing for Manual Therapists. 3rd ed. Baltimore: Lippincott Williams &
Wilkins, 2006.)