Capture Case History Essentials

My first post in the Massage Charting Method Collaboration (MCMC) described problems in the current practice of charting for massage therapists, and I presented arguments and guidelines in its formation.  I received very helpful feedback on the proposed case history template via social media and direct email and incorporated some of those changes here.

I have a second template to share for your perusal – the RMT initial assessment.  The RMT initial assessment template allows you to capture the essential information from the case history template, blend it with information gathered from your further questioning and create a comprehensive symptom picture you can use to determine your course of treatment and identify any contra-indications to care.

The purpose of this template is to weave together the patient/client’s reported symptoms and goals, your observations and assessment, and outcomes from treatment based on your benchmarks – all on one page for easy review.  This page ideally is fastened to the back of the case history template so all this comprehensive information is stored on one page.

There are added advantages to this template over existing practices as well.  You’ll see prompts on the left side of the page to ensure you’re asking all the important questions, with questions particular to yellow/red flags (see Neuromusculoskeletal Examination and Assessment by Petty/Moore) to immediately identify risk of harm to the patient/client and lessen practitioner liability from performing an inadeqate case history.

Also presented under the Objective and Assessment portions are seven relevant and measurable benchmarks for massage practitioners to gage improvement (outcomes) from their interventions.  I’ve added mood as a variable, given the mounting research showing a beneficial outcome of massage therapy on mood.  Most of these measures are rehabilitative/medical in basis but we’ll need to add further benchmarks to consider the wellness goals (that is, not necessarily disease-based) of the patient/client.

If you’re an RMTAO member, you can read my article 7 Ways to Measure Massage Therapy Interventions to learn more about these benchmarks, or wait for my next post where I’ll elaborate on how to document these.

Please sign up for our blog and post your comments on the proposed templates below, or join in the discussion on Facebook.  We’ll make RMT charting better…together.

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