Massage Therapy Documentation
Patient Name:
Record Number:
Date of Service:
Pre- Therapy Pain Score:
* See reverse side for scales
Use scale below
None Mild Moderate Severe Pain as bad as it could possibly be
Patient Self- Assessment:
Therapist Assessment:
Technique:
Area of Body:
Lotion:
Results/ Comments:
Session Notes:
Post-Therapy Pain Score:
* See reverse side for scales
Use scale below
None Mild Moderate Severe Pain as bad as it could possibly be
Planned Visit Frequency:
Frequency Changes:
Signature:
https://porterhills.sharepoint.com/sites/ehsclinicalstaff2/shared documents/form/massage therapy documentation.docx
Updated: 09.16.2016
Overall Intensity
Verbal Self- Report:
*Select from Drop Down Menu to Enter the number or level reported by patient
*No Pain 0
1
2
3
4
5
6
7
8
9
10 * Worst Possible Pain
one – Denies Pain
Mild
Moderate
Severe
Non-Verbal Report:
Pain Assessment IN Advanced Dementia- PAINAD (Warden, Hurley, Volicer, 2003)
Items
0
1
2
Score
Breathing:
Independent of
vocalization
Normal
Occasional labored
breathing. Short
period of
hyperventilation
Noisy labored breathing. Long period of
hyperventilation. Cheyne-stokes
respirations.
Negative
Vocalization
None
Occasional moan or
groan. Low-level of
speech with a
negative or
disapproving quality
Repeated troubled calling out. Loud
moaning or groaning. Crying
Facial Expression
Smiling or
inexpressive
Sad, frightened,
frown
Facial grimacing
Body Language
Relaxed
Tense, distressed,
pacing and/or
fidgeting
Rigid, fists clenched, knees pulled up,
pulling or pushing away, striking out
Consolable
No need to
console
Distracted or
reassured by voice
or touch
Unable to console, distract or reassure
Total
Notes:
https://porterhills.sharepoint.com/sites/ehsclinicalstaff2/shared documents/form/massage therapy documentation.docx
Updated: 09.16.2016