Documentation *increasing* liability risks?

[Dewayne]

Today it was suggested to me that keeping session notes can increase liability and that perhaps it's better not to keep any. My first reaction was, "That's ridiculous," but I wanted to get your thoughts.

 

[Surfing Instructor]

In our wonderfully warped legal system, it certainly could increase your liability.

If you get dragged into a medical claims trial, an atty could obtain your treatment records. An "expert witness" could find something they disagree with in your records and voila, you become a contributing factor.

 

[oldscholl88]

Yeah, I think it certainly could increase your liability, for the reasons R&R said.

I am curious if there is some legal thing that we have to keep notes and how long we have to keep them for. And if there is, where would that law or regulation be found? It's not in my state massage laws, that I can recall.

 

[Peppe]

In my Business & Ethics class, we were told to keep very good notes. However, in my internship interview (with the same instructor), I was told that "less is better" when it came to SOAP notes. I thought that was a bit odd, but considering liability factors, I am learning that my natural penchant for detail may NOT exactly be in my favor.

 

[R. A]

I don't even like the soap format for my work. The software I use uses this format, but I don't fill it in exactly as normal soap charting would call for. I tweek it for my own use.

 

[Nekomimi 13]

I don't even like the soap format for my work. The software I use uses this format, but I don't fill it in exactly as normal soap charting would call for. I tweek it for my own use.

I hate the SOAP format!! Doctors notes are nowhere near as extensive as what we were taught in school, lol!! I have the SOAP format, so use it, but when I run out of forms I am seriously considering documenting the way doctors do. I'm sure mine would be more than "ct complaint is....., perscription for .......... given", but I'd seriously save some paper.

 

[Elana A]

Yeah, I think it certainly could increase your liability, for the reasons R&R said.

I am curious if there is some legal thing that we have to keep notes and how long we have to keep them for. And if there is, where would that law or regulation be found? It's not in my state massage laws, that I can recall.

I dont think there is a legal time..... in one of my classes they said to keep them for 5 years, since that's how long the Dr's are by law suppose to keep notes for.

 

[Anish]

One of my instructors at massage school worked part time for an attorney, interpreting SOAP notes for his cases. She gave us tips on things she looked for when they were reviewing cases, where information was incomplete... or too much was said. For the most part though, less was more, unless the therapist were doing work related to injuries from an accident (or similar case where insurance/blame of a third party was likely to be involved.)

I'll have to admit though, I'm WAY out practice in writing SOAPs, since my current job doesn't require them.

 

[dinogirl69]

One of my instructors at massage school worked part time for an attorney, interpreting SOAP notes for his cases. She gave us tips on things she looked for when they were reviewing cases, where information was incomplete... or too much was said. For the most part though, less was more, unless the therapist were doing work related to injuries from an accident (or similar case where insurance/blame of a third party was likely to be involved.)

I'll have to admit though, I'm WAY out practice in writing SOAPs, since my current job doesn't require them.

What kind of SOAPS did they see? Physicians? Dental?? I've never seen another industry use the format, but I've only read charting from MD offices and hospitals. They don't really use a format, just jot some notes - are they still called SOAPS?

 

[brookie1977m]

I know that speech pathologists (at least while in grad school) learn to do SOAP charting as well..

 

[ldyblucpl]

Wow, thanks...

So the specific issue is around hot stone massage. I'm thinking of a recent thread where the OP's client claimed to have been burned and the OP had, among other things, documentation that she checked in with the client, there were no problems, etc.

If you were doing hot stone massage, what would you say offers the least liabilty:
- no documentation
- basic documentation
- extensive documentation

 

[reds]

ROS - I don't recall what professions were covered, I just remembered that it was a side thing that she did.

EgoMagickian reminded me of some examples - one being the use of hydroculator packs. It was suggested we note the appearance of the skin before application, note the number of towels between the HP and the client, the clients response when checking in re their comfort level (specifically if they're ok with the temp), the amount of time the HP is used, and the appearance of the skin after treatment. Also of importance, is asking the client how they feel at the end of the massage - if they say they feel great, relaxed, etc, it kinda takes some of the wind out of their sails if they claim foul afterwards.

She said it's assumed that we're going to be massaging, so we don't necessarily have to list all the different techniques used, though locations of trigger points or anything notable is beneficial for future sessions. I believe where most people got into trouble was consistency. If you're going to get specific about detailing something in particular, ALWAYS detail it. I can't think of a great example offhand, but let's say you always use a particular lotion on a client because they've stated they have allergies, and you're in the habit of noting what particular lotion you're using in your notes. If you DON'T make note of it on some occasion and the client comes back later to say you used the wrong lotion on them and they had a reaction because of it, then there is an inconsistency someone might grab onto. Again, not a great example, but all I could come up with at the moment. lol

 

[lollipopsy]

If you were doing hot stone massage, what would you say offers the least liabilty:
- no documentation
- basic documentation
- extensive documentation

If any regulations require documentation, then No Documentation creates the Maximum Liability. When you don't follow the rules, you have no defense. In that case, Extensive Docs protect you the most.

If you are not required to maintain documentation, then you should probably only document by exception to CYA.

 

[Jessica P]

If you are not required to maintain documentation, then you should probably only document by exception to CYA.

This means document only if out of the ordinary things occur?

 

[Pompal 09.]

Yep

 

[Ian]

When doing any type of hot stone therapy I think it is necessary to at least document the temperature of the stones and that you checked in with the client.

On my form, I also have a notice that says it is the clients responsibility to inform the therapist if the stones or too hot or uncomfortable and they waive any liability that occurs due to them not speaking up--- not written in those words exactly but you get the meaning. The client has to sign this before they can have the treatment.

 

[Jaguar Jones is uncouth]

You should document. It will protect you rather than he said she said argument. If your in California, there is the sb577 health freedom law that says you have to have education disclosure form and other disclosures that your not license by the state as healthcare provider and other stuff. do a search for it. you'll find it. Documentation will protect you as it records what you did. If you did anything wrong in the session your not suppose to than you'll be an idiot to document such as you'll self incriminate yourself. And the idea of documenting only when something is fishy won't hold in court as there is no consistency. Do the soap notes or don't. no in between. Of course there is another way to document. the holistic health model uses the DAR charting. Nurses use them too. D is for data , subjective or objective information in the session. A is for action done in the session. R is for response, results or reaction of the session. If you were practicing without the sb577 disclosure form require in CA. than tough luck when you get into a lawsuit as liability insurance isn't covered if you don't follow the required law. Most people still don't know about that law.

Also charting is great for marketing. Just let your clients know that your one of the few who does it. Most other places don't do it and you doing it show you care for them and not treating massage as a pampering service but more of a preventative health care which is massage's core essence. Also in this economy, you want to market massage not being luxury pampering. people will pay for massage that get rid of pain and kinks rather than paying the same or more for doctor visit and pain killing drugs. they will not pay for pampering in this economy when everyone is getting laid of left and right. Of course rich corrupt execs and ceo's don't mind paying for the pampering massage. why? it's cuz they let their companies take the fall while they pocket all the money so they can sit back and easily flow through the bad economy. Look at execs for AIG, they spent 200000 bucks on spa the first weekend they got bailout fund and did it again the next week with that high expense. yes, they charge to company and not from their own pocket. this is just one example why the economy is bad. large corps that spend borrow money frivolously.

 

[Pompal 09.]

I feel that NOT charting is a greater risk. If you keep records consistently, you have a data mine to draw upon should legal issues arise.

For example, a MT was sued for causing a neck injury... but that MT had SOAPs documenting that the client had come to them for treatment of whiplash, improved dramatically in 4 visits, and resumed athletic activity. Later on, this client needed some cash and visited an attorney. The MT's SOAP records sufficiently undermined the lawsuit such that it was dismissed.

My instructors and some of my business colleagues advocate keeping "all your SOAPs, forever." One of my massage instructors was sued by a former client that she had last treated 16 years prior. Going into her records, my instructor was able to produce the original treatment notes. The SOAP from that session disproved the legal claim.

As a business owner, I am aware that medical testimony may find fault with something contained in a SOAP written by one of our MTs. However, by consistently documenting each session and making that info available for review prior to subsequent sessions, we are able to better serve clients that see multiple MTs at our location. Because our MTs refer clients to each other for various types of work, the SOAPs provide a critical information link.

Last, I feel that male MTs need to take SOAPs seriously, especially if working independently. In school, I included descriptions of the draping and bolstering used in each session. This built a consistent documented record of the steps I took to maintain appropriate physical boundaries during each session. If someone was to later complain that I'd been sloppy and left them exposed, I could produce evidence otherwise.

 

[Henry Le]

wow, 16 yrs back. Instructor didn't need to redo soap chart. Just call for late filing of lawsuit. Isn't the statue of limitation 2 yrs for negligence lawsuit? well, in CA. it's 2 yrs.

Yup. male therapist have to do soap notes or some documentation so they see you seriously. especially in this day and age of bad economy where people will do anything when things get tough. people will try to sue for harassment to make a quick buck. males are easy target. document show professionalism.

Just the other day , it was on the news that a person who got laid off went and murder the person that fired him. sad times I say because when things get tough, the passionate heart gets put on the side and emotions will control one's behavior. especially with people who just see money and nothing else.