Treatment must match Diagnosis
According to the insurance industry, we as massage therapists are not considered qualified to diagnose. All of the notes about our treatment must relate VERY DIRECTLY to the doctors diagnosis. You and I all know that everything in the body is connected, but the insurance industry takes things more literally. For example, if the diagnosis is “sprain or strain of the muscles and tendons of the cervical spine”, it would be reasonable if you indicated a hypertonic splenius capitis, but not necessarily a hypertonic piriformis. I think you get the idea, if not, please ask me in a phone call.
If the patient is having any symptoms from the accident that are not consistent with the diagnosis, or imply additional injuries, it is important to write them in in the “S”ubjective section of the notes. While technically we are only allowed to treat what is on the diagnosis, documenting other pains from the accident help create a paper trail that may help the client in the future. If you feel there is a glaring misdiagnosis, please tell the patient to talk to their doctor about getting it corrected.
Session Dates
Read the treatment plan and look at the start and end dates.
Work Comp, you cannot go over the expiration by even 1 day.
No-Fault is just slightly more flexible and some adjusters may be more lenient that others. By default we use the most conservative interpretation which allows for up to a week of flexibility depending on the start date: For example, say you start the prescription 4 days after it was issued, then you can go 4 days past the expiration date. This is true for starting up to a week after the start date. Clients can ask their adjusters for extensions if special circumstances warrant and we will note those in the case file.
Our week begins on Monday and Ends on Sunday. Make sure not to do more sessions in a week then specified. If the client is seeing more than one therapist, work with the client to make sure you don’t exceed the sessions per week.
Online SOAP Note System
If its your first time, ask the office to send you the activation link.
Login from the link on the therapist info page.
When you login, you will see a list of your clients and their prescriptions on the “My Prescriptions” page.
Click a clients name to get their phone number to contact them.
Click on the prescription number to get to the “Prescription Detail” page where you can see the treatment plan, the diagnosis, and how many treatment notes have been filed.
If you need more details like a the doctors notes, or an MRI result, please ask the office.
Click New Soap Note to enter your note.
All of the information in a SOAP note including the DOS can be changed up until the time you electronically sign the note by hitting the Submit button.
After you submit the note, if you want to save a PDF of the SOAP for your own records, click the “completed….” link on the right of the relavent DOS.
If you want to see all the sessions you have submitted for all clients and and which ones have been paid, choose “My Session Log” in the menu:
(In future versions we hope to incorporate progress reports and release documents into this same system)