For all but the last session, include a "treatment plan" section
Under "Treatment Plan", record:
Example: “30 minutes deep tissue massage, lower back, 2 times per week for 3 weeks, to decrease adhesion.”
For your patient's last session, include a "discharge notes" section instead of a "treatment plan".
Under "Discharge Notes" record:
Use this section to record instructions, assignments and exercises given to the patient. Do not forget to be specific and provide detailed instructions to your clients.
Example: “Initiate stretching of back for 2 minutes every hour spent at the computer. Gave back stretching handout #3.”
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