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Why are we using generic when we have specific needs?

Generic medical forms were developed by Dr. Lawrence Weed in the 1960's at the University of Vermont. The SOAP format of the generic medical forms originated from the Problem Oriented Medical Record (POMR). It was developed for doctors as a way to document patient progress. Now in the twenty first century, many care providers still use this same generic medical note format. Various registered health professionals, from physicians, nurses, pharmacists, podiatrists, chiropractors, physical therapists, occupational therapists, and massage therapists often use this documentation method. Many registered health professionals use the SOAP format even though specific practitioners, or regulatory bodies, often have more specific requirements that exceeds the four fields contained in this format (subjective, objective, assessment, plan).

As I entered my seventh year as a practicing Massage Therapist, I found myself questioning the efficacy of using such a generic form for my specific profession. When I researched the documentation options available to our profession, it became apparent that many companies only provide this generic medical note format to meet our diverse charting needs. This is the same format that a surgeon uses for post-operative notes. It is the same note that a podiatrist might use to chart minor procedures. As massage therapists, why are we not asking for a more specific charting methods? If we are not, we are limiting the amount of information we can input into a client or patient’s file.

The CMTO, Canadian Massage Therapist of Ontario, has sample downloads to print and use, but none of their examples use the generic charting method. The examples from our own college model a very specific way of charting – they do not try to cram important details and information into one generic SOAP form. The sample forms include inputting for each of the following separately:

  • the patient’s health history
  • the treatment plan
  • the therapist’s assessment, and
  • the treatment notes

There are a minimum of forty fields that legislation and scope of practice require massage therapists to input in the client health file. Of those forty, 16 are on the initial Health History, the objective aspect of the generic form. At a minimum, there are still 24 more fields, if an assessment of a physical complaint is done, and another 7—12 fields to make note of on an average form. That leaves a range of 24—36 fields to input into 3 remaining parts of the generic medical form.

By using the generic format, the therapist has to fit all that information into the remaining 3 sections. That is a lot of typing, or a lot of handwriting. Either way that cannot be done easily with any type of speed, accuracy, or consistency. The treatment plan alone, a subsection of the health file that is dictated by Communication and Public Health standard #10 found in the CMTO standards of practice, lists 8 required fields. If using paper, how many practicing therapists have a separate paper that contains the vital 8 components within that document? If using a paperless software, are all 8 fields prompted for inputting before the document is allowed to be saved digitally?

We need to ask for, demand even, appropriate RMT charting software that reflects our clinical skillset. Clinical skills, like any other learned skill, needs to be exercised to be kept at a high level of aptitude. When doing our records, whether it be on paper or using paperless options provided by companies hosting digital records, we should demand a high level charting method. When going paperless, we should seek out companies providing electronic record keeping with a product of the highest quality, truly legislation compliant specific to massage therapy. Why are we using generic when we have specific needs?

J. Sarah Armstrong,

B.Sc. (Hons), RMT

CEO DigitalRMT.com

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Visit www.digitalrmt.com to see the new, profession specific way to chart your client's files.

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Welcome to our discussion page for Canada's Registered Massage Therapists. DigitalRMT was created because the options available in electronic charting for massage therapists were not meeting the needs of many of todays therapists. Most companies are using the generic SOAP note format, but the CMTO has a minimum of 40 required fields for our charting. So Sarah Armstrong, B.Sc., RMT, created her own templates on her laptop. During a regular peer review, the auditor was overwhelmed with how complete the four forms were. That generated a discussion between Ms Armstrong and the peer reviewer on how many of todays records are not keeping up with the CMTO's standards, even paper records. The peer reviewer was very enthusiastic that this type of record keeping should be available to all therapists. So, DigitalRMT was created to elevate the options available to the therapists in Canada.

Keep your eyes open for the upcoming articles on this page that aim to generate discussion and improve therapists awareness of record keeping issues.