Help need massage therapy soap notes asap??

Question

need to say that patient's b*****s are causing pain in the neck and upper back at a severe, constant rate, can't find any soap note forms???

Answer 1

You don't need a form, just a blank piece of paper in the patient folder and write this down.

Date of entry

S = Pt c/o severe nk & UBP. Pt rates px on VAS of ___ (enter 0 - 10). Pain is ____ (localized, radiates down arms/back/wrist/hands). Pt notices px started on (enter date), and it is constant throughout the day. Pt finds relief with _______ (meds, therapy, or extra bra support).

O = Hypertonic and muscle spasm with (list involved muscles). Trigger points noted in (list involved muscles).

A = Nk px & UBP may be attributed to pendulous/excessive size b*****s.

P = Soft tissue therapy / trigger point therapy with (list muscles). Recommended pt to purchase orthopedic upper back support for women. [doublecheck to see if this is within your scope, if not, then refer to MD so he can recommend pt to purchase the support or even breast reduction surgery if warranted.]

Sign entry.

That's all you need to say.

Answer 2

There are tons of forms online at various websites.

Answer 3

All you need is plain paper or lined paper.

Just write it out long hand.

S: patient complains of breast pain, which also causes pain in the neck & upper back- pain is severe & constant.

O: fill in what you find- trigger points, tender etc.

A: whatever your assesment is

P: write what you did today & any home care or referral & when you plan to see her again.

We have used both a printed form w/ the S O A P down the side, & blanks for name & date at the top, as well as plain lined paper.

My massage therapist just designed a SOAP form w/ a body on it that she can mark areas of complaint on it as well.

You don't need anything that fancy today, just write your notes & work on designing another form later.