Informed Consent and SOAP Notes

Informed Consent

Refers to the voluntary agreement given by a competent individual to receive a massage treatment

What Must a Client be Informed on?

Nature, potential benefits, risks, alternatives, scope of practice, confidentiality

Nature of Treatment

Provide a clear treatment of the type of massage therapy treatments being offered

What are some Potential Benefits?

Relaxation, stress relief, pain reduction, improved circulation, increased ROM

What are some Potential Risks or Limitations?

Possible soreness, bruising, or exacerbation of certain medical treatment

Scope of Practice

Communicate the therapists’ qualifications, certifications and area of expertise

What are the Two Specific Populations?

Minors & Vulnerable Populations

What is the Rule for Minors?

16 or Older: They can make their own health decisions

15 or Younger: They cannot make their own health decisions

What is the Rule for Minors in Manitoba?

Persons 16 years of age or older are legally able to give consent, unless they demonstrate otherwise

What is a Vulnerable Population?

An individual with:

Cognitive Impairments

Someone who Cannot Communicate Effectively

How do you Work With Vulnerable Populations?

You work with their legally authorized representative or caregiver

How is Consent Continuity Achieved?

Regularly Check in With Clients

Ensure Clients Comfort

Adjust Clients Treatment Plan as Needed

What are SOAP Notes

The documentation that the Massage Therapist writes about the client they are seeing

What does SOAP stand for in SOAP Notes?

Subjective, Objective, Analysis, Plan

What Information is Found in the (S)ubjective Section?

Chief Complaint, History, Pain Level and Location, Additional Information

What Information is Found in the (O)bjective Section?

Observations and findings such as Postural Assessments, Range of Motion, Palpation Findings, and Other Assessments

What Information is Found in the (A)nalysis Section?

Problem Identification, Casual Factors, Treatment Goals

What Information is Found in the (P)lan Section?

Treatment Performed & Techniques used, Treatment Frequency & Duration, Homecare, and Referrals

Considerations when Writing SOAP Notes

Ensure accuracy, clarity, and objectivity; be concise; avoid personal opinions; maintain client confidentiality; adhere to legal and ethical guidelines

Why are SOAP Notes Essential?

They facilitate effective communication, community of care, and informed decision-making for therapists and clients

Questions to Ask During Consult

What is it?

How Long?

Treatment?

Current Status?