Documentation templates

The first SRN-webinar was held in the International Shiatsu Congress Online 2020 on the topic Case Reports. During this webinar the participating shiatsu practitioners stated they would like the SRN to provide some templates for documenting the intake in the first meeting and the subsequent treatment notes. Discussions among an international group of volunteers (Leisa Bellmore, Karin Koers, Claudia Leyh-Dexheimer, Kristina Pfeifer, Tamara Odermatt and Sandy Gsell) led to the development of the templates:

Initial intake

Treatment notes of the following meetings

Comments / Explanation for interview and treatment notes

German versions:

Dokumentation Erstgespräch

Behandlungsprotokoll

Kommentare zu Dokumentation und Behandlungsprotkollen

For those of you who prefer to take notes on an empty piece of paper, we provide key codes below. It is recommended to get used to the treatment notes above before working with the key codes.

Key codes for flow text writing

In the following you learn about the relevance of documentation, the initial intake, the active participation of your client by goal setting and the documentation of the client’s healing process in the treatment notes.

Why is it relevant for shiatsu practitioners to document our client’s cases in a structured way?

The open structure of the template for the initial intake with the client provides you individual flexibility and supports you in capturing important aspects of their health and their needs. Additionally, you will find many ideas for questions in our template to guide the conversation with the client. Asking about changes of the client’s concerns or symptoms raises the awareness of the client to the health promoting process and documenting those in the treatment notes is a matter of quality control in your practice. Writing down client’s feedback, your observations or perceptions, treatment strategies as well as the assessment of your strategy allows you to look back on the client’s healing process and your interventions later on. This is the first step to verbalize your experience and enables you to discuss this with other practitioners. It will deepen your understanding of the healing process of your client, but not only that: You will become aware of your own process by reflecting on what you do, what you feel, what you perceive, what you decide or where you give an open space during the treatments. To use this kind of documentation presented here is not research, but it is a solid basis to start with research since its use sharpens your observation skills and ensures that you have enough information documented in case you want to write a case report.

Documentation of the initial intake

Please download the templates and the comments we provide above. We provide comments to the intake template and the treatment notes in order to clarify the meaning of the aspects noted in the templates. A summary of the comments is found below.

The intake template starts with some general information, which are self-explanatory, like Name, Address, Phone, Date of Birth. This is followed by information about the client’s Occupation and Family status, which are often helpful to assess the social life, emotional stress or workload. An important part of the intake is the clarification of the clients’s concern. Besides opening-questions like “What brings you to me?” you will find in the comments to the templates a list of questions to find out precisely what the concern is about. The answers often give interesting hints for shiatsu-specific approaches like the five elements. Moreover, we would like to encourage you to reflect on your own limitations by asking yourself:

  • Can I treat this patient?
  • Where do I need to be careful?
  • Is it necessary for the patient to see another specialist?

Such reflection is part of professional ethics which aims at ensuring the client’s safety. Furthermore, the next aspects, current therapies and drugs as well as illnesses, injuries, health issues, support you in gathering sufficient information to assess the client’s safety and adapt your treatment.

There is space for lifestyle, diet and leisure activities to complete the client’s profile before you guide your client to set his or her goal for the treatment cycle. Are you familiar with goal setting?

To establish a goal in the first treatment of a cycle, you might ask a question like ‘What do you want from Shiatsu?’ The obvious goal which is often the response: ‘I want to get rid of my pain or symptom XY’, might be appropriate in case of well-defined symptoms. But it is neither a response which activates the self-efficacy of the client, nor a positive response. In order to promote the self-efficacy of the client a goal with ‘I’ and the use of a verb in present is recommended. If clients use initially modal verbs like  can, may, must, shall, will, they can be invited to rephrase their sentence without modal. Asking the question above the client might answer only ‘Relaxation’ or ‘Well-being’, with such short answers it is worthwhile to find out more about the context of this wish, which may lead to a more precise goal. Maybe the clients wishing ‘Relaxation’ have a very stressful job situation. In these cases, a goal might be ‘I handle stressful situations better’, which emphasises the client’s own responsibility to improve self-regulation or to take better care of themselves. Shiatsu and Shiatsu practitioners then support the clients change processes by providing a save space as well as their bodywork. In some cases, an unaddressed trauma response prevents the sympathetic excitation from being reduced. In this situation our work might focus, as Cliff Andrews described in “A Brief Guide to Treating Stress and Trauma with Shiatsu and TCM”, on getting “’back in touch’ with their body-mind connection”. A goal like ‘I handle stressful situations better’ would be inappropriate because clients with trauma can be ‘trapped’ in a high stress state because they have a dysfunctional self-regulation. But especially for clients with trauma it is important to encourage self-efficacy and one way to do this is active participation in the treatment planning (e.g. goal setting).

Another approach to work with goals and wishes is to contrast the goal/wish by the obstacle which prevents the clients from reaching their goal. This method called WOOP is very simple and supplements the positiv “Wish” and “Outcome” by the negativ “Obstacle” as basis for a very simple “Plan” supporting the ability to act. More information about this evidence based method you find under https://woopmylife.org/en/home (available in many languages).

Talking about goals shows the clients, they are taken seriously and helps to develop trust and a safe therapeutic relationship. Moreover, it brings more clarity and the clients can actively participate in the treatment planning, which activates their self-efficacy and their own responsibility.

Treatment notes

From the second treatment onwards, the protocol starts with the feedback of the client on reactions to the last treatment and the changes the client observed since then. This is followed by today’s concerns/symptoms where the client’s physical, mental or emotional state and the concern for today’s treatment is clarified. There is space for Bo Shin, Bun Shin and Mon Shin, range of motion, postural observations as well as other observations and perceptions in observations before treatment. This will also help later on to note the changes after the treatment. Before or after the treatment you may review the goal: The client’s goal gives orientation during the healing process, but the new concern and / or changes in the client’s symptoms may mean that the client’s original goal should be adjusted. Assess together with the client whether the goal is still appropriate or needs to be changed.

Under treatment you can document everything relevant to the treatment (findings, meridians, Setsu Shin, reactions of the clients, your own etc.). What did you treat? What was your focus? Did it change during the treatment? Did you perceive anything special?

During the reassessment you can ask the clients if the treatment fulfilled their concern and how their body perception has changed as a result of the treatment. Note also your observations after the treatment and the changes you noticed. Under ongoing treatment plan write down what strategy idea you had and what you might address in the next session. You can also note how today’s treatment relates to the overall goal and if in the next session an adjustment of the goal is necessary.

Coming to the end of the treatment protocol we have one point left: Self-care

How can clients support themselves between treatments? Be aware of and make use of inner and outer resources (own strengths and support): Social activities, body, breathing and mindfulness exercises, nutrition, maintaining one’s own boundaries, etc..

We hope many practitioners start to use our templates. Don’t hesitate to give us some feedback via admin@shiatsu-research-network.org or to subscribe to our newsletter or our roundtable.

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