Initial Evaluation (IE) and Documentation for Medical Massage
The first visit (Initial Evaluation, IE) is a critical component of a patient’s recovery. Your documentation not only justifies treatment but also becomes part of the patient’s medical history, ensuring continuity of care.
Since insurance claims require thorough documentation, it’s essential that your notes are detailed and professional.
Initial Evaluation Components
Your initial evaluation should include:
✅ Comprehensive patient intake
✅ Detailed documentation of the patient’s chief complaints, functional limitations, and treatment goals
✅ Objective findings and assessment
✅ Plan for ongoing care
For Veterans Affairs (VA) patients, include a detailed description of the treatment provided.
Subjective Section
The subjective section includes information provided by the patient—not your observations. This is key for:
Gathering medical history
Creating specific, measurable goals
Ruling out contraindications
Include the Following:
✔️ Patient information (age, sex, injury details, chronic vs. acute pain)
✔️ Date & cause of injury
✔️ Pain score (0–10 scale)
✔️ Functional limitations (e.g., difficulty walking, sleeping, sitting)
✔️ Other treatments, medications, imaging (X-ray, MRI, etc.)
✔️ Patient’s treatment goals
Example Questions to Ask:
How can I help you today?
How did your pain start? Was there an injury?
How long have you had these symptoms?
How would you rate your pain on a scale of 0–10?
How does this pain affect your daily activities (sleep, walking, work, self-care)?
Are you taking pain medication? How often?
Have you tried other treatments (chiropractic, PT, massage, etc.)?
What are your goals for treatment?
Example Subjective Entry:
Patient is a 42-year-old male Veteran referred for massage therapy due to lower back and neck pain. He reports sustaining an injury two years ago after a fall while on active duty. Over the past year, his lower back pain has worsened (8/10) with radicular symptoms into the right leg. Neck pain is reported as 6/10 with no radicular symptoms.
He has tried chiropractic care with only temporary relief. X-rays of the lumbar and cervical spine were negative. He takes daily opioids for pain and NSAIDs as needed. His pain disrupts his sleep (limited to two hours at a time) and affects his ability to perform self-care and household tasks.
His goals for massage therapy include improved sleep, reduced pain medication use, and returning to a walking program.
Objective Section
The objective section records your observed findings, including:
✔️ Posture analysis
✔️ Skin temperature & tissue tension
✔️ Range of Motion (ROM) assessment
✔️ Functional deficits (e.g., difficulty transferring, walking, or standing)
Example Objective Entry:
Patient presents with lower back and neck pain, accompanied by severe muscle spasms. Mobility is significantly reduced, making transfers onto the treatment table difficult.
Assessment Section
Summarize the subjective and objective findings, patient’s response to treatment, and any modifications needed for future sessions.
If longer sessions (e.g., 60 minutes) are required, justify this with a detailed analysis.
Example Assessment Entry:
Patient was referred for massage therapy with a diagnosis of lower back and neck pain. He presents with pain, muscle spasms, and decreased ROM in the neck and lower back, preventing him from sleeping and performing daily activities.
After today’s session, pain reduced from 8/10 to 5/10, with decreased muscle spasms in the lower back. Given the severity of symptoms and the need to address multiple areas, I recommend 60-minute sessions.
Treatment Section
Document:
✔️ Modalities used (e.g., trigger point therapy, deep tissue massage)
✔️ Body parts treated (include left, right, or bilateral distinctions)
✔️ Stretching or education provided
Example Treatment Entry:
Provided neuromuscular therapy (NMT) and trigger point therapy to the lower back bilaterally. Applied deep tissue massage to the right gluteal region and hamstrings. Also treated the neck and shoulder musculature bilaterally. Educated the patient on proper sitting posture and demonstrated hamstring/quadriceps stretches for mobility improvement.
Plan Section
Set 3–4 functional, measurable goals based on the patient’s limitations. If another provider may work with the patient, include any planned modifications for future sessions.
Example Goals:
✅ Reduce lower back pain to 4/10 to allow for 5 hours of uninterrupted sleep.
✅ Minimize muscle spasms to improve low back flexibility, making it easier to put on shoes and socks.
✅ Decrease pain to 2/10 or less to allow the patient to resume walking activities.
✅ Enable patient to walk ½ mile pain-free.
Example Plan Entry:
Plan to add trigger point therapy to the neck musculature in the next session.
Notes for Medical Review
At the end of documentation, you will see a checkbox for "Notes for Medical Review."
✔️ Check this box ONLY IF:
You observe something outside the scope of massage therapy (e.g., untreated injury, hazardous living conditions).
❌ Do NOT check this box to alert Zeel of completed notes—Zeel automatically reviews all submissions.
❌ Do NOT use this checkbox for emergencies—Dial 911 if immediate medical attention is needed.
Pro Tip:
Before submitting, review your notes for accuracy, spelling, and clarity—these records reflect your professionalism and quality of care.
What Comes After the Initial Evaluation?
For subsequent visits (except the final one):
Continue working toward the goals set in the initial evaluation.
If goals or techniques change, document these updates in the Plan section.
For the final session of the referral:
Conduct a comprehensive assessment to evaluate progress toward initial goals.
Determine next steps:
✔️ Discharge if goals are met.
✔️ Refer back to the physician if alternative treatment is needed.
✔️ Request additional sessions if progress is ongoing but incomplete (see Submitting a Request for Additional Service (RFS)).
Examples of Goal Statuses:
✅ Goal achieved
✅ Progressing toward goal
✅ Goals not met
✅ Referred back to physician or VA Medical Center (VAMC)