Observation and what you feel under your hands as you work on a client and what your client says are important written notes for each session. Using both reflex and anatomical terms in documenting all sessions is part of practicing in a professional manner by meeting industry business standards.
Other reasons to document your sessions include they are a place to note:
1. Client’s chief complaint or reason for coming that day.
2. Any changes in their health history they may be experiencing (i.e., more stress at work, a cold/flu, worsening of a relationship, etc.)
3. Using both anatomical and reflexology terms areas of sensitivity (i.e., the medial head of the first metatarsal instead of the reflex area related to the thyroid gland, because depending on the chart used the area may be labeled something else).
4. The response to previous reflexology session.
5. Session progress by reviewing and comparing (i.e., was there improvement in sensitivity indicated by a lessening, staying the same or increasing in an area?) Don’t trust your memory.
6. How long it has been between sessions.
7. Areas of emphasis that you came back to during the session for more work.
8. Comments by the client as to techniques s/he liked or amount of pressure used.
9. For marketing purposes personal information about the client (i.e., their birthday so you can send a card or email).
10. Referral to another health care practitioner—legally this can be important whether or not the client follows-up.
Remember client documentations are legal documents. They can be subpoenaed in legal or insurance cases so it is important to watch your vocabulary. Do not diagnose, prescribe, or treat for a specific illness—always quote the client (i.e., the client reported….)
Learn more about documenting your sessions through the ARCB certification process.