Massage therapist Dr's note??
I own been working with a client for almost 2 years presently, she has had upper vertebrae and neck/shoulder pain due to a very hulking chest.
Dr said no breast reduction because of her body type, and a lift is recommended, not covered by Insurance, she requirements me to write a note, should I use soaps notes, anyone enjoy any suggestions?
Answer: Yes...SOAP notes are the standard. As well as a report..
Be sure to document the muscles that are strained from the load of her breast tissue: pectralis major and minor are overly tight, latisumus dorsi overly stretched, etc. Has your client ALWAYS had back/neck/shoulder throbbing from her large mammary glands her whole entire time? If the answer is no, then she does not require surgery of any kind, unless she desires it for cosmetic purposes only. If she has NOT have back/neck/shoulder pain continuously, then you obligation to look at muscle usage from a kinesiologist's point of view. We had a markedly similar question on one of our final exams, with the merciful presenting with extra-large mammary glands, with back/neck/shoulder affliction. It was actually overuse of dependable muscles, including SCM, scalenes, upper traps, levator scapula, etc. If you can't figure it out, then find a chiropractor that uses kinesiology and refer her for a second evaluation. Kinesiology uses different techinques to restore muscle usage. What you are probably doing is relaxing the muscle through massage (which is what you are supposed to do), but if the correct muscles are not working properly, her vertebrae pain will return. Other muscles to consider are glutes and abdominals. If these muscle groups, the largest in the intact body, are not functioning properly, then other muscles MUST take over the function of keeping her adjectives. In which case, her chest has nil to do with her back distress.
Try anything to avoid surgery..
Use your soap notes, but you need to enjoy your client sign a release form first. Our soap's are no different than the medical records at a hospital or doctors office. If you release the annals without signed consent, you can get into closely of legal issues like the HIPAA privacy regulations. It wouldn't be a impossible idea to write a summery stating the condition of your client when she came to you and how she's progressed, or digressed. Don't use plain English...We are cog of the medical field too, whether some like it or not, and should speak the argot when appropriate. OK she needs to see another doctor.
A lift won't support her one bit, she needs a REDUCTION!
A lift individual lifts it, not reduces, it would be a gamble away of spent money because she'll just sag again.
She desires to talk to another doctor/PS and find someone who will send within information to the insurance company to get covered..
Use plain english, and document how long you have be seeing her, and what her complaints as well as her pain extent ratings. Your history dealing with these types of things wouldn't hurt either.