Issue link: http://cp.revolio.com/i/142672
effective record keeping By Diana Thompson Why is it such a struggle to keep written records of our sessions? Were we not taught to chart in school, or if we were, perhaps our teachers were not good role models in this area so we didn't take it seriously? Did we learn to chart clients whose insurance demanded charts before reimbursement checks were cut, leaving us off the hook from charting the rest of our clientele? Did we get out of the habit once it no longer meant a better grade? Perhaps we were not provided enough choices in charting formats and lost faith in the benefits of charting. Even if we are practiced in charting, how do we choose which information is appropriate to record and which information could potentially cause problems later? Clear and consistent written communication does not have to be complicated. It needs to flow naturally and become a part of the healing atmosphere and the tender care you provide your clientele. This task is easily incorporated if the benefits are evident with each return visit. Every word that is written, when reread before the next session, can teach you how to better understand clients' needs and deliver a customized session that keeps them coming back. If you can accomplish this, you will have fewer problems keeping written, Clear and consistent legal documents that benefit you, your clients, other health-care team members, and your bottom line. The theme of this feature is: keep it simple. Learn three levels of basic record keeping that build on gathering a brief health history sufficient to provide a safe and effective massage and bodywork session. First, understand the minimum information required for maintaining a medical record. Second, record information essential to tracking minor aches and pains. Finally, chart enough details to note changes in the client's goals and health status. Sidebars will provide a deeper application of charting: communicating with insurance companies through functional outcomes reporting and a CPT code update for insurance billing. Whether verbal or written, an initial interview collects the following information: Intake Questions Goals. What do they hope to Every client session begins with an interview: polite introductions and a few questions to assess safety and comfort. "Do you have any specific requests for today's session?" "Is there anything I should know about you today to tailor this session to meet your needs and ensure your comfort?" "How would you like to feel when you leave here today?" These questions are not as blunt or impersonal as "Where does it hurt?" which is a conversation stopper when there is no presence of pain. Ask questions that invite a warm and caring relationship and collect details that help you design a session that makes the client feel heard and respected. written communication does not have to be complicated. It needs to flow naturally and become a part of the healing atmosphere and the tender care you provide your clientele. accomplish in the session or series of sessions? Tailor your session to meet their needs. Symptoms. Are they currently experiencing any pain or tenderness, stiffness, loss of function, swelling, numbness, or tingling? Ask them to prioritize their needs, honor their requests. Health history. Are there previous injuries, surgeries or illnesses, and conditions currently cared for with a physician or by taking medications? Are there contraindications or cautions that require you to modify the treatment? Medications and allergies. Find out what might interact negatively