Issue link: http://cp.revolio.com/i/142672
effective record keeping their health and well-being. We need to take our responsibilities seriously by keeping a record of our sessions. Level two. The next level of record keeping is to write down information clients share before they get on the table, such as, "I cannot seem to rotate my right wrist as much as I can my left when doing bench curls at the gym," or "It is getting harder to turn my head to the right when backing out of the drive." Typically clients mention a symptom (stiffness) and associate it with an activity (exercise, driving). Both are critical pieces of information. If we only record "stiff wrist," we loose the opportunity to ground the detail in an everyday activity and therefore miss the chance to quantify progress or to ask an appropriate follow-up question. Two critical pieces of information are best recorded together: 1) how clients feel, and 2) what clients are doing when they notice how they feel. Experiencing pain, by itself, is not enough information to be helpful. If you write "pain in neck" every session, the ability to note change or progress is lost. Knowing when it hurts and when it doesn't hurt, and how much clients have to modify what they are doing because of how much it hurts speaks volumes. Tracking clients' minor aches and pains and the activities that trigger them can help them identify patterns or behaviors and make needed adjustments. Maintaining perspective of clients' conditions also helps keep them cognizant of their progress. Level three. The next level of basic record keeping is to assess the severity of any symptoms clients mention by considering how much it affects their activities. When clients are basically healthy, there is not much to report beyond the treatment provided. However, whenever clients say they feel stiff or tender or tired, write it down and place it in a measurable context. This can be as simple as describing how an activity is affected by the symptom or assigning a number between 0–10, with 10 representing disabled or bedridden. If there is no change in activity, the symptom is considered mild or can be rated a 1, 2, or 3, out of 10. If symptoms cause a client to modify one or more daily activities, such as fewer trips to the gym or lighter loads of groceries from the car, the symptom is moderate or is rated a 4, 5, or 6, out of 10. If the client is unable to perform some activities, such as run, ski, or lift weights, the condition is severe and can be rated 7, 8, or 9, out of 10. The more activities affected by the symptom, the higher the number between 0–10. Completing the Task In summary, the following should be recorded on a wellness chart. • oals for the session. Why G are they there and how would they like to feel upon leaving? • Symptoms. Do they have any tenderness or pain, stiffness, numbness, or is there anything they would like to improve on? Rate the symptom on a scale of 0–10. • ctivities of daily living. Are A there activities impacted by how they feel, such as their ability to sleep, work, exercise, or do household chores? Are they limiting their activities or changing how they would normally perform the activity to avoid the pain? Specify what they are able to do in relation to their previous ability. • reatment. What you did (deepT tissue massage). Why (to relieve tight trapezoids and pectoral muscles). Where you did it (full body, focus on neck, chest, and shoulders). Duration (60 minutes). Once a symptom has been measured, progress can be easily noted. Change happens slowly sometimes, sometimes quickly, but rarely does it happen instantaneously and permanently. Someone with pain in the low back that prevents them from lifting their grandchild often goes through various stages of healing, setbacks, and transformations that deserve to be recorded. Without recording the level of severity, all we can surmise is that the pain is present until it is completely gone. We should always be able to identify detailed progress. It is quite remarkable to be able to state that the client's pain is now a 3 out of 10 from a 6 out of 10 and the client can lift that 5-year-old grandchild into the highchair, but has a new goal of lifting the child and bending over to put the child into the car seat. This is a motivating story of progress, deserving of additional sessions to help them reach their new goal. SPH Diana L. Thompson is a licensed massage practitioner, educator, and author of Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists.