Initial Evaluation (IE) and Documentation for Medical Massage
The first visit, or initial evaluation, with a medical massage patient is a critical component of their recovery. During this visit, you’ll paint a picture of the patient’s condition that will not only help justify the treatment, but will become part of the patient’s medical history, allowing future practitioners to understand them more holistically. This documentation is also required in insurance claims for each treatment, so it’s imperative that it be thorough and professional.
An initial evaluation should include a comprehensive patient intake with detailed documentation describing the patient’s chief complaints, objective and functional limitations. This will help you outline a goal-based plan for the patient’s full course of massage therapy.
IE documentation contains a subjective history, a detailed objective examination, an assessment of the patient (based on treatment response and a summary of your subjective and objective findings), and a goal-based plan for the treatment. When working with Veterans, providers must also include a detailed description of the treatment provided.
Below we’ll examine what this all means, and how to apply it to your patient.
Subjective
This section consists of information the patient gives you—not your observations—and is a crucial step for gathering their medical history. Obtaining a thorough history from the patient is essential for creating specific, high-quality goals and ruling out any potential contraindications to treatment.
This will include the patient’s age, sex, injury (if applicable), date and cause of injury, chronic versus acute pain, pain score, and functional scale. You should note any other treatments the patient is undergoing, past medical history (PMH), medications, imaging (x-ray, MRI, etc.). Additionally, ask the patient what their treatment goals are.
Examples of questions you may ask, in order to obtain a complete subjective history:
How can I help you today? This allows them an open forum to explain their specific issues and their goals for therapy. For individuals who don’t provide a lot of detail, you can guide them with more specific questions:
How did your pain start? Was there a specific injury or accident that brought about your symptoms?
How long have your symptoms been going on (days, weeks, years)?
How would you grade your pain on a 0–10 scale, with 0 being no pain and 10 being maximal pain?
How does this pain affect you functionally? (e.g. sleep, walking, sitting, self-care, household chores, work activities, recreation)
Are you currently taking pain medication for your symptoms? If so, how often?
Are you currently, or have you previously, undergone any other forms of treatment for this condition?
Have you had any imaging for this injury (e.g. x-ray, MRI, ultrasound)
What are your goals for treatment?
EXAMPLE: Patient is a 42-year-old male Veteran, referred for massage therapy with a diagnosis of lower back and neck pain. The patient reports that he injured his lower back and neck 2 years ago in a fall while still on active duty.
The patient reports that his pain has intensified over the past year. Lower back pain reported as 8/10 with radicular symptoms into the right lower extremity down to his foot; neck pain is 6/10 on a pain scale with no radicular symptoms.
He states that he has tried chiropractic care previously, but it only provided temporary relief. He reports that x-rays in both the lumbar and cervical spine were negative and states that he takes opioid medication daily for pain relief and NSAIDs as needed.
Currently, he states that his back and neck pain prevent him from sleeping more than 2 hours at a time and that he has great difficulty performing self-care and activities around the home that require him to bend and squat. His goals for massage therapy are improved sleep, decreased need for pain medication and a return to a walking program
Objective
In this section you will record observed findings, including patient posture, skin temperature, tissue tension, ROM, and functional deficits (transfers, gait, etc.). This is primarily a summary of the intake questions you are prompted to ask in the Zeel Provider App, but you can also provide a short summary of your findings.
EXAMPLE: The patient presents with lower back and neck pain with severe muscle spasms. He presents with decreased mobility in the lower back making transferring onto the treatment table difficult.
Assessment
Here you should summarize what the patient told you in the subjective section, your objective findings, and how the patient responded to today’s treatment. If you feel that longer sessions (i.e. 60 minutes) are medically advisable, please indicate this here, but remember to include a detailed analysis that justifies your request.
EXAMPLE: Patient was referred for massage therapy with a diagnosis of low back and neck pain. He presents with pain, muscle spasm, and decreased ROM in the neck and lower back, preventing him from sleeping through the night and severely affecting his ability to perform ADLs (activities of daily living). The patient responded well to today’s session and reported less pain (5/10) and reduction in muscles spasms in the lower back. I feel that 60 minute sessions are indicated, based on the severity of the patient's symptoms, as well as the need to treat multiple body parts.
Treatment
A comprehensive treatment section should be included that indicates the specific modalities provided during the treatment. You should also include the specific body parts treated, the side of the body (left, right or bilaterally), and any specific treatment techniques (e.g. reflexology, myofascial release).
EXAMPLE: Treatment consisted of NMT and trigger point therapy to the lower back bilaterally. Deep tissue massage to the right gluteal region and right hamstring. Treatment also included deep tissue massage and trigger point therapy to the neck and shoulder musculature bilaterally. The patient was instructed in lower extremity (hamstring and quadriceps) stretching to assist with mobility and was educated on proper sitting posture.
Plan
The plan should include 3-4 goals that you will work towards in the remaining treatments. These goals should be specific and reflect the patient’s unique circumstances. They should also be measurable and speak to functional outcomes. You can use the information gathered in the subjective portion of the exam to create goals from the specific limitations you want to improve.
You can also add anything you plan to change for the next session or as a note for another provider working with your patient.
EXAMPLE:
Goal 1: Reduce lower back pain to 4/10 to allow the patient to sleep 5 consecutive hours. (A poor example would be “decrease low back pain,” which is neither measurable nor geared toward functional improvement.)
Goal 2: Decrease lower back muscle spasm from severe to minimal to improve low back flexion, making donning shoes and socks easier
Goal 3: Decrease lower back pain to 2/10 or less to allow the patient to return to walking activities.
Goal 4: The patient will be able to walk ½ mile pain free
Plan to add trigger point therapy to the neck musculature next session.
Notes for Medical Review
At the end of the documentation process you will see a checkbox for “Notes for Medical Review.” Check this box only if you observe something outside the scope of massage therapy that a clinician should be made aware of. This could include something hazardous in the patient’s living conditions, an untreated injury or wound, or a worsening condition unrelated to their pain referral.
You do not need to check this box to alert Zeel that you’ve completed your notes. We automatically review every submission. DO NOT use this checkbox to indicate a medical emergency; dial 911 in an emergency scenario.
PRO TIP: Once you’ve filled out all the sections of the evaluation, take a few minutes to read back through your notes and make any corrections for accuracy, spelling, or clarity. You should treat this like any professional document, as it is representative of the care you put into being a medical professional.
What Comes After the Initial Evaluation?
During all the subsequent visits (except the final one), you will work with the patient to address the stated functional limitations and goals. If during the course of treatment, your techniques or goals change, you should clearly document this in the plan section of your follow-up notes. But typically in follow-up sessions you will be working towards the goals you developed during your initial evaluation.
In the final session of a referral, you will return to a more comprehensive documentation process, similar to the first visit. You will assess how the patient responded to the overall course of treatment and how they progressed towards the goals set at the time of IE. At this time, you will make the following determination:
Has the patient met their goals, making them eligible for discharge from treatment, OR
Do they need to be referred back to the referring physician to assess alternative treatment options, OR
Is the patient making sufficient progress toward their goals with massage to benefit from additional massage sessions? If so, a request for additional services can be submitted on the patient’s behalf (see the article “Submitting a Request for Additional Service (RFS)” to learn more).
Examples of goal statuses:
Goal achieved
Progressing towards goal
Goals not met
Referred back to referring physician or VAMC for follow up