SOAP Notes, Treatment Plans, and Consent Forms
Learn How to Properly Document in RMT Clinics
Why Documentation is Non-Negotiable
Documentation is the backbone of professional practice. It’s not just for insurance—it’s the evidence that shows you provided safe, ethical, and effective care.
Without it, you’re exposed. If a patient files a complaint and your notes are incomplete, CMTO may assume non-compliance.
SOAP Notes – The Gold Standard
SOAP stands for:
- S – Subjective: What the patient says (symptoms, pain level, history).
- O – Objective: What you observe (range of motion, palpation findings).
- A – Assessment: Your clinical reasoning and decision-making.
- P – Plan: What treatment was given, response, and next steps.
Pro tip: Always write as if another RMT (or CMTO investigator) had to read it tomorrow. Would it make sense?
Consent – More Than a Signature
- Consent must be informed: the patient knows what, why, risks, and alternatives.
- It must be ongoing: check in during treatment if techniques change.
- Best practice: document consent in your SOAP note (verbal consent given, written consent signed, etc.).
- Treatment Plans – Insurance & Clinical Protection
- Outline goals (pain relief, mobility, stress reduction).
- Specify frequency and duration (e.g., 6 sessions over 6 weeks).
- Document adjustments as patient needs evolve.
Insurance companies love clear treatment plans—it makes predetermination approvals easier.
Case Study: SOAP Notes That Saved an RMT
An Ottawa RMT faced an insurance audit. Because her SOAP notes clearly showed treatment goals and progress, the insurer approved all pending claims. No clawbacks.
📌 Download our SOAP Note Template today and bring your documentation up to CMTO gold standards.
