Is your Massage Therapy Intake Form Compliant?
How do you make sure your massage therapy intake form is compliant? It is often said that great therapy starts at intake. Why is that?
The intake process constitutes the first formal contact between the therapist and the client. It is what follows naturally after the initial introduction. A thorough intake process helps the therapist to understand the client’s specific circumstances and design a personal treatment plan accordingly. This is crucial, as people’s health issues and ailments vary, and consequently, treatment must be considered on an individual basis.
Usually, intake includes an initial interview, as well as, a process of filling in the forms, done by both the therapist and the client. If there are issues that do not appear on the Massage Therapy Intake Form but were discussed in the interview, they may be added subsequently through the SOAPs, as discussed below.
Effective tried and tested intake processes make use of a dedicated document. The Massage Therapy Intake Form is intended to provide the therapist with the client’s health history and lists previous medical interventions. It is also an opportunity for the therapist to offer the client information about the intended therapy, as well as, lay down important legal rules and boundaries.
Many therapists provide the client with a copy of the Massage Therapy Intake Form, for completion prior to the initial interview. At the outset, the Massage Therapy Intake Form contains the client’s contact information. This includes a contact number, email address, home address, additional phone numbers and date of birth.
Other details (employment status, earnings, Socioeconomic Status (SES, based on client’s economic and social position in relation to others, based on income, education, and occupation).
It has been shown that Socioeconomic Status (SES) correlates with unhealthy behaviors like smoking, lack of exercise, poor diet and obesity. Studies suggest that people with low socioeconomic status showed increased levels of stress coupled with reduced self-care. They exercised less and ate more. In certain communities, people’s Body Mass Index (BMI) was inversely related to their SES.
The Massage Therapy Intake Form includes other information that serves to help the therapist to exclude from the intended therapy certain aspects that are contraindicated for a specific client. These aspects may include allergies, past accidents, injuries, and physical disabilities, surgeries, pregnancy, the medication the client is currently using, and other medical issues the therapist should be aware of.
By listing current medical challenges or ailments in the Massage Therapy Intake Form, either by the clients themselves or through an assessment done by the therapist, an indication will emerge as to the type of treatment (location and intensity) required.
If, for example, the client complains of a sore Iliotibial Bands or ITBs on the Massage Therapy Intake Form, the therapist could decide that the client may require deep tissue work to the hip flexors, as well as, knee extensors and antagonist knee flexors, instead of applying only stress relief or relaxation massage.
Example of a Washington State intake consent form HERE.
Other elements that may be used in the Massage Therapy Intake Forms to increase the treatment plan effectiveness further are body maps and assessment charts. These allow therapists to track trigger points and ranges of motion, chart strengths of muscles and note any tissue characteristics.
Certain Massage Therapy Intake Forms have detailed checkbox lists of various pathologies such as:
- neck pain
- sleeping problems
- back pain
- chest pains
- shortness of breath
- digestive conditions
- high or low blood pressure
- cardiovascular condition
- loss of balance
- skin conditions
- thigh pain
- pubic pain
- difficulty swallowing
- cold hands or feet
- double vision
- chronic pain
- respiratory conditions
- infectious conditions
- multiple sclerosis
- leg / calf cramps
- neurological conditions
- pins & needles: in legs, arms, fingers and toes
Others may include a section for patients to list their preferred type of massage and areas to focus on or avoid.
A popular, effective use of body maps and assessment charts include “pain drawings”, used to obtain information about the location of pain on the client’s body. These tools are qualitative in nature – the client may indicate a specific painful spot or an area, he/she may use a rating system, such as numbering pain from 0 – no pain, to 10 – excruciating pain, and update the “pain drawing” periodically.
Sometimes – especially with older clients – a checklist of body parts may prove to be more effective. When using body maps or charts to measure pain, focus points are the intensity, frequency, and duration of the pain. Other symptoms may be charged separately.
Some states require a confidentiality disclosure as part of the Massage Therapy Intake Form. If insurance is accepted, a Health Insurance Portability and Accountability Act of 1996 agreement (HIPAA) is mandatory and is often completed in addition to the Massage Therapy Intake Form. The HIPAA agreement ensures confidentiality and restricts access to one’s healthcare information.
HIPAA regulations require that all licensed therapists should obtain a signed release form from their client before they are permitted to take any notes about the client. This is usually done during the initial interview. Therapists should have this form signed before taking any notes.
Clients may request to receive a copy of the form they signed, and the therapists must maintain a copy for their records. In that regard, it is emphasized that confidentiality of medical and personal information obtained during therapy is of the utmost importance.
Licensed Massage Therapists use the initial interview and the Massage Therapy Intake Form – the first bit of information provided by the client – to lay down a treatment plan. As therapy progresses, information in the initial form is expanded with details based on a documentation technique known as SOAP (SOAP stands for Subjective, Objective, Assessment and Plan).
With Subjective information supplied by the client, Objective information observed by the therapist, information Assessed during palpation or treatment and Plans that were subsequently formed by the therapist. These four parts of the therapist report – Subjective data, Objective observation, information gained through Assessment, and the subsequent Plan formed, as well as the initial Massage Therapy Intake Form, are used to track each client’s progress.
SOAPs, for example, may contain a detailed chronological record of contacts with or about the client, other than therapy sessions. For example, if the therapist contacted the clients personal doctor, gym trainer or employer, or if the therapist asks for – or releases – information regarding a client.
According to The American Physical Therapy Association (APTA) guidelines, SOAP Notes should include self-report of the patient, details of the specific intervention provided and equipment used. Further, notes regarding changes in patient status, including complications or adverse reactions.
Other input includes listing factors that may have changed the therapy process, progression towards the stated goals in treatment and communication with other providers of care, the patient and their family.
FREE Massage Therapy Client Intake and SOAP Note Forms can be found at: https://www.amtamassage.org/career_guidance/detail/211
The four aspects of SOAP in therapy address various viewpoints as to the process:
The Subjective viewpoint deals with a client’s own perspective on their journey – how they feel about their progress,
if they are able to function without pain or discomfort and on what level, and how/if their quality of life improves over time.
The Objective viewpoint is that of the therapist and his/her observations of the process. This is where body maps and charts are especially effective.
The Assessment viewpoint is a critical observation of the therapists’ work – how he/she reached an opinion based on the two previous sections, why he/she made the specific treatment decisions based on the patient’s unique problem, and how he/she intends to work with the client on their journey (goals) and any factors that affect these goals.
The Plan viewpoint considers the formal planning (strategic and tactical) of further treatment. This is used to cover any potential upcoming treatments, as well as, client home exercises between sessions.
In addition to the Massage Therapy Intake Forms and SOAPs, the Informed Consent Agreement for Massage Therapy Sessions helps the therapist to lay out in writing both the expectations and the limitations to the expectations a client may have in relation to the Massage Therapy session.
The informed consent form is usually used in conjunction with the client Intake Form and subsequent SOAPs. From the client’s point of view, the Informed Consent Agreement offers an opportunity to choose whether or not to receive the suggested Massage Therapy services offered. It is also a safeguard related to potential liability issues that may arise at any time.
The Informed Consent Agreement may include a description of the therapist’s approach to massage, as well as, the modality and techniques used. The benefits, limitations, and contraindications of the proposed treatment plans may also be listed, as well as, the possible outcomes — making sure that this does not imply any guaranteed outcome. Other aspects of the treatment describe may include the nature of a session, including the process of disrobing and draping.
Here are some free massage Intake and S.O.A.P. forms.
Also listed may be the therapist’s credentials and areas of expertise, as well as the scope of practice, skills, and limitations, based on the therapist’s credentials. Added, too, is the therapist’s undertaking to maintain client confidentiality and privacy.
Finally, session duration and fees payable, as well as, cancellations and late arrival policies may be listed together with insurance reimbursement capabilities, if any, service availability and hours of operation and lastly – a potential collaboration with other health professionals.
The client is required to read the Informed Consent Agreement thoroughly, discuss any unclear issue with the therapist and, having been satisfied with the details laid out in the agreement, sign it. A standard summation of an Informed Consent Agreement, states that “I have read the above-noted consent and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by my therapist from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.”
In essence, the Massage Therapy Intake Form comprises of the totality of available information about the client, the SOAPs represent the documentation of ongoing therapy, and the Informed Consent Agreement articulates the client’s expressed understanding of the therapist’s services, as well as, an expressed consent to receive them.
The client understands the following pertinent aspects for consideration, brought here for information purposes only and not as legal or professional advice, should not be used without consulting one’s individual legal advisor for all the relevant and specific circumstances:
• Understands the message is given for the purpose of (stress reduction, pain reduction, relief from muscle tension, increasing circulation, or specific reasons stated here).
• That the massage therapist does not diagnose illness or disease and does not prescribe medical treatment or pharmaceuticals, nor are spinal manipulations part of Massage Therapy.
• That Massage Therapy is not a substitute for medical care and that it is recommended that one should work with one’s primary caregiver for any condition he/she may have.
• Acknowledges having stated all his/her known physical conditions and medications and will keep the massage therapist updated on any changes.
• Signature and personal identification details.
Lastly, why use a Massage Therapy Intake Form? There are 8 overriding reasons to do that:
1. The process is streamlined and standardized. All important information is listed, so clients can fill it in and it is available for consideration at all times.
2. The Form, together with the SOAPs and the Informed Consent Agreement establish a dynamic, well-documented timeline of the treatment provided.
3. It is an effective client screening tool, as it addresses issues related to the type and quality of the information provided (address, for example, as well as names and identification details).
4. The Form documents the fact that various aspect of the service has been explained to the client, who indicated having understood the terms and agreed to them.
5. The Form may be used for risk management, ascertaining, for example, if the client provided the correct medical history and medication information.
6. The Form enables the therapist to ascertain which services are required, as well as, considering other services, both in-house and outsourced.
7. The Form can be used to validate insurance information, eligibility for cover etc.
8. Making it easier to comply with legal requirements regarding patient’s private information (such as HIPAA).
It appears, then, that when we say that great therapy starts at intake, we address three main needs, shared by therapists and clients alike. Firstly, there is a quest for an improvement, even gradual and incomplete, of one’s physical well-being in the face of a daily struggle with pain. The client seeks relief, while the therapist strives to offer effective treatment.
The second needs is that of the profession – the need to devise an effective, observable plan, a strategy aims to serve the client’s need, using measurable methods. This need answers the client’s ability to follow the way treatment is devised, as well as, the results, which may help also for insurance purposes. Finally, the needs of the therapist and the client meet the formal needs of the legal system.
Here the Informed Consent Agreement comes to play as a formal contract between the therapist who undertakes to provide a specific service, and the client, who consents to undergo treatment. To learn more about how to keep your Massage Intake Form compliant, contact a massage therapist professional at DiscoveryPoint School Of Massage.