Massage Therapy Documentation and Software for a Successful Practice

Massage therapy has come a long way not only in the mind of the public but also the medical establishment. There are times when it's covered by insurance which means more paperwork for the massage therapist. But it also means the chance to earn more money and help those who otherwise wouldn't be able to afford therapeutic massage services.

Besides insurance billing, massage therapists need to keep other records. Special documentation that therapists might need are consent forms, MT-specific invoices and evaluation forms such as SOAP notes. Below, I explain these different types of documents further and how they'll benefit your massage therapy business.

The intake form is where the client's basic information is gathered; work, phone, address and emergency contact info. This is also where you can ask specific questions that will give you a clue as to any contraindications for massage including health concerns and any physician instructions given to the patient regarding massage.

The consent form, also called a release form, can actually be part of the intake or a separate document altogether. One purpose is to help protect the MT from liability, though massage therapy liability insurance is imperative to have for this too. For instance, clients may be harmed if they neglect to tell their MT about past injuries. The MT would be open to a lawsuit, but a release form may help for defense against this.

You can create a basic combination intake and consent form with the following components:

• Basic client info, i.e. name, address, phone, work.
• Emergency contact person and phone number.
• Current complaints and why they're receiving massage therapy.
• Past medical history, especially that pertinent to current complaint.
• Consent paragraph stating that the client has given you all necessary info and doesn't hold you liable for problems that arise from medical history not mentioned. A statement that the client understands that the MT does not diagnose problems and massage therapy is not meant to be used to replace other medical care should be included.
  

Most of the time, clients pay for massage services at the time they're rendered. There are, however, different settings that may require invoices to be given to the client such as seated workplace massage. Often, an MT will have a contract with a company to do massage on a certain schedule and then invoice the company which will pay according to agreed upon terms.

A computer-generated invoice is often used for this which includes the company name, MT business name and info, a list of services rendered and the net terms of payment. Another option is an invoice book purchased from an office supply store which usually includes invoices with duplicate copies so the MT can keep track of them.

SOAP is the acronym for Subjective, Objective, Assessment and Plan. These types of reports are used often in medical settings including hospitals, family medical centers, chiropractors and physical therapists.

If you're a massage therapist who works in a medical setting, then you've likely come across them. But they aren't just for MTs who work in a traditional medical establishment. If you're working on a specific bodywork goal with a client, SOAP notes are an excellent way to document your progress and keep track of what works and what doesn't.

Here is the format briefly explained (further explained in link below):

• Subjective: How the client is feeling and the history of the complaint.
• Objective: How you perceive the client's condition at this time through observation.
• Assessment: The conclusion you've reached about the nature of their condition from your observation.
• Plan: Your plan of treatment.

You can create a basic SOAP note by creating the four sections in a word document and leaving enough room for you to write or type your evaluation under each heading. There's also SOAP note software for different medical specialties. Some massage therapy software packages may even include SOAP notes tailored to the needs of the MT office. Massage Office Professional from the Island Software Company and Massage Suite are two top software programs used by massage therapists that include SOAP note capability.

Insurance billing requires codes for specific health problems and treatment used for reimbursement. MTs will usually need to work in conjunction with the client's physician to know what codes to use. An insurer may not send reimbursement if the MT is not under the supervision of a doctor. However, this will vary by provider and local and federal laws.

The massage therapy software mentioned above includes coding and billing information. You may also want to take a course or two in insurance billing to get a grasp on this complex subject. An excellent resource for more information is the Massage Insurance Billing website.

If an MT is an employee, then much of the work of accounting and office management will be carried out by the employer. But self-employed MTs need to have sound accounting practices like any other small business owner which is beyond the scope of this article. However, some basics you will want to consider for your office are:

• An appointment calendar, either paper or electronic or both or appointment software.
  
• Office suite software such as Microsoft Office with Excel which you can create spreadsheets with for basic accounting.
  
• Publishing software (i.e. Microsoft Publisher included with Office) to create custom invoices, letterhead, business cards, brochures, etc.

Massage therapy documentation can be simple or complex depending on the needs of the MT. Developing good record keeping practices now will help your business grow and leave you more time to practice the art and science of massage rather than worrying about mountains of paperwork.