Massage therapist Dr's note??

Question

I have been working with a client for almost 2 years now, she has had upper back and neck/shoulder pain due to a very large chest.

Dr said no breast reduction because of her body type, and a lift is recommended, not covered by Insurance, she needs me to write a note, should I use soaps notes, anyone have any suggestions?

Answer 1

Be sure to document the muscles that are strained from the heaviness of her breast tissue:  pectralis major and minor are overly tight, latisumus dorsi overly stretched, etc.   Has your client ALWAYS had back/neck/shoulder pain from her large mammary glands her whole entire life?  If the answer is no, then she does not require surgery of any kind, unless she wants it for cosmetic purposes only.  If she has NOT had back/neck/shoulder pain continuously, then you need to look at muscle usage from a kinesiologist's point of view.   We had a very similar question on one of our final exams, with the patient presenting with extra-large mammary glands, with back/neck/shoulder pain.  It was actually overuse of certain muscles, including SCM, scalenes, upper traps, levator scapula, etc.  If you can't figure it out, then find a chiropractor that uses kinesiology and refer her for a second opinion.  Kinesiology uses different techinques to restore muscle usage.  What you are probably doing is relaxing the muscle through massage (which is what you are supposed to do), but if the correct muscles are not working properly, her back pain will return.  Other muscles to consider are glutes and abdominals.  If these muscle groups, the largest in the whole body, are not functioning properly, then other muscles MUST take over the function of keeping her upright.  In which case, her chest has nothing to do with her back pain.  

Try anything to avoid surgery.

Answer 2

OK she needs to see another doctor.

A lift won't help her one bit, she needs a REDUCTION!!!

A lift only lifts it, not reduces, it would be a waste of spent money because she'll just sag again.

She needs to talk to another doctor/PS and find someone who will send in information to the insurance company to get covered.

Answer 3

Use your soap notes, but you need to have your client sign a release form first.  Our soap's are no different than the medical records at a hospital or doctors office.  If you release the records without signed consent, you can get into a lot of legal issues like the HIPAA privacy regulations.  It wouldn't be a bad idea to write a summery stating the condition of your client when she came to you and how she's progressed, or digressed.  Don't use plain English...We are part of the medical field too, whether some like it or not, and should speak the language when appropriate.

Answer 4

Yes...SOAP notes are the standard.  As well as a report.

Answer 5

Use plain english, and document how long you have been seeing her, and what her complaints as well as her pain scale ratings. Your history dealing with these types of things wouldn't hurt either.