Hiya
I work at a chiropractors clinic as a sports massage therapist (but I also offer relaxing massage too) and we have had a new therapist join us (newly qualified I believe) recently, the head chiropractor/owner of the clinic has asked me if I'd have a friendly chat with the new therapist about the lack of detail provided on the consult forms following a treatment.
I like to have as much detail as possible using abbreviations when possible for example the new therapist would write "massage to neck/shoulders", I would write down what muscles I have tested/assessed the results of that, what muscle I have concentrated on for example traps and lev scap and how tight and tender they are. Oh and what techniques I've used eg: STR, NMR, MET etc. Do others write in details there findings, I was always lead to believe that its important to be able to recount what you have done, even if it is years later.
I look forward to hearing what others think. 😀
Cheers
SpikeyJo 🙂
In a clinic, where the client is likely to be seen by multiple therapists, then the notes should be detailed. For sole provider purposes, it probably wouldn't need to be too detailed - but I like to be able to look back through my notes for red flags, or to remind myself what may have been a 'problem' a few treatments ago, but is now resolved.
As a clinic member, the new therapist must conform to the clinic protocols - including detailed note taking.
Thanks Jabba thats my feelings, its a very new clinic and I was the first therapist there, so I was given the task of adapting the forms used by the Chiropractor. Like you I like to look back and see how things have progressed. Unfortunately English is not the first language of the new therapist so must be more difficult for them!
Thanks