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In the practice of massage therapy it is important that the documentation of client problems and treatment history be consistent, concise comprehensive and up to date. Many massage therapists use the SOAP Note format to standardize their client records.

SOAP is an acronym that stands for Subjective observations, Objective observations, Assessment and Plan.

The purpose of the SOAP Note is to document the client's condition and record their progress after each massage session. SOAP Notes can help the therapist track the effectiveness of treatment techniques and to determine whether or not the treatment need to be adjusted in future sessions to better address the client's problem areas.

The four parts of a SOAP Note are described below.

SOAP Note - S is for SUBJECTIVE

This initial portion of the SOAP note is made up of subjective observations. These are symptoms the client verbally expresses to the massage therapist. The subjective observations should include the client's descriptions of:

• The way they feel
• Past history
• Problem or injury details
• Current symptoms
• Limitations caused by the problem or injury
• What makes them feel better or worse

It is helpful for the therapist to ask the client to rate their pain or discomfort on a level 1-10 with 10 being the worst. This allows the therapist to see improvements or setbacks as time goes on.

SOAP Note - O is for OBJECTIVE

This part of the SOAP Note is the objective observations. These objective observations include symptoms that the massage therapists can actually see or feel. The subjective observations should include the therapist's observations about the clients:

• Posture
• Mobility
• General Weaknesses
• Joint Movement
• Skin Color
• Skin Temperature
• Swelling
• Muscle Texture
• Muscle Spasms
• Breathing Patterns

It is also useful to test the client's range of motion in different areas and track their changes from session to session.

SOAP Note - A is for ASSESSMENT

Massage Therapists use this part of the SOAP Note to document the immediate results of a treatment. At the end of a session the therapist reanalyzes and documents the changes in the client's posture and range of motion. This part of the report should indicate the amount of change that occurred by ranking the progress - None, Mild, Moderate or Significant.

SOAP Note - P is for PLAN

The last part of the SOAP Note is the treatment plan. The plan should include:

• Treatment Frequency Recommendations
• Home Care Instructions
• Recommended Exercises
• Reminders for Next Session