The Best Way to Write Soap Notes For Massage Therapist

Soap Notes For Massage Therapist | Quick Guide with AI

It's 8 PM on a Tuesday, and you're exhausted from back-to-back massage sessions all day.

Your hands are tired, your body is sore, and the last thing you want to do is sit down and document six client sessions.

But you know you have to. Insurance companies need it. Your professional liability depends on it. And honestly, you need it to track your clients' progress.

Sound familiar? If you've ever found yourself in these shoes, keep on reading.

We've all been here.

Quick Tip

SOAP Notes Doctor is our product that transforms recordings, audios, and text into industry-standard SOAP notes.

You can let it listen to your session and do the work.

You can add, edit, review, and more context later.

Head over to soapnotes.doctor now.

Let's dive in.

SOAP Notes: The Quick Story

Back in the day, massage therapy documentation was basically whatever you felt like writing.

One therapist might write "client complained about lower back - did deep tissue" while another would write three pages about every muscle fiber they touched.

Some remembered to include treatment duration and others might forget entirely that dates were even a thing.

This was the wild west of documentation until Dr. Lawrence Weed came along in the late 1960s and said "we can do better."

He created a standardized system called the Problem-Oriented Medical Record, with SOAP notes as its cornerstone.

His brilliant idea was simple: give everyone the same template so any professional could read someone else's notes and actually understand what happened.

Here's what Dr. Weed came up with:

• S (Subjective): What the client tells you about their pain, tension, and goals
• O (Objective): What you observe and feel during assessment and treatment
• A (Assessment): Your professional take on how the session went and what you found
• P (Plan): What happens next and what the client should do at home

This format caught on like wildfire because it just made sense.

Soon it spread from hospitals to physical therapy clinics, chiropractic offices, and eventually to massage therapy practices everywhere.

How to Write SOAP Notes for Massage Therapists: My Recommended Approach

When I started working with massage therapists, I'd hear the same complaint over and over: "I love the bodywork, but I hate the paperwork."

Then I discovered something that changed everything:

"Just get it done. Don't overthink it."

Document what you felt, what you did, and how the client responded. That's your foundation. Everything else is extra.

I picked this mindset up from watching successful massage therapists work efficiently, and I built soapnotes.doctor around it.

There are technically two ways you can approach SOAP notes. You can write them manually, or you can use soapnotes.doctor.

Use soapnotes.doctor

I'll choose soapnotes.doctor every day since it's consistent, accurate, and most importantly, faster than handwritten notes.

Here's how to streamline the whole process:

1. Head over to soapnotes.doctor to get started. Complete the onboarding process if you're new to the platform.

2. Click on the record button to either record the whole session with the client or dictate (if you feel that would be better).

3. Wait 1-3 minutes.

4. Review and save.

One beauty of soapnotes.doctor is that the tool is just good. Not superfluous, yet never misses detail. I think that's the best of both worlds.

And if for whatever reason you choose to make edits, you have the tailorr feature at your disposal. Edit, approve, add context, and copy to your EMR.

Write Manually

Maybe you're old school and prefer typing it out yourself. Here's how to do it without overthinking.

The trick is to never see SOAP Notes as writing a novel. You're documenting a treatment, not writing an essay.

1. S - Subjective

This is like the intake conversation before you even touch the client.

This section should capture your client's perspective and set the foundation for the entire session.

Purpose: Document what your client tells you about their condition, concerns, and goals.

What to include:

• Chief complaint or reason for seeking massage therapy
• Pain levels (using 1-10 scale)
• Duration and onset of symptoms
• Previous treatments or relevant medical history
• Client's goals for the session
• Any changes since the last visit

Examples:

"Client reports lower back pain at 7/10, onset 3 days ago after lifting boxes at work. States pain is constant, aching sensation that worsens when sitting. Goal is to reduce pain and improve mobility for return to work activities."

"Client arrived reporting tension headaches occurring 3-4 times weekly over the past month. Describes stress level as 8/10 due to work deadlines. Seeking relaxation and stress relief."

2. O - Objective

If anything, this is where you want to be specific about what you felt and observed.

The objective section is where you document your professional observations and measurable findings during the assessment and treatment.

Purpose: Record factual, observable data about the client's condition and response to treatment.

What to include:

• Postural observations
• Range of motion measurements
• Palpation findings (muscle tension, trigger points, temperature)
• Techniques used during treatment
• Duration of massage and areas treated
• Client's physiological responses during treatment

Examples:

"Observed forward head posture and elevated right shoulder. Palpation revealed moderate tension in upper trapezius bilaterally with trigger points noted in right levator scapulae. Applied 60-minute Swedish massage focusing on neck, shoulders, and upper back using moderate pressure."

"Client demonstrated limited lumbar flexion (fingertips to mid-shin). Significant muscle guarding noted in erector spinae L3-L5. Performed 45-minute therapeutic massage using deep tissue techniques, myofascial release, and trigger point therapy to lumbar region."

3. A - Assessment

This section provides your professional analysis of the client's condition and response to treatment.

Purpose: Connect the subjective complaints with objective findings and evaluate treatment effectiveness.

Key Principle: Focus on clinical reasoning and treatment outcomes rather than lengthy narratives.

What to include:

• How the client responded to specific techniques
• Changes in muscle tension, pain levels, or range of motion
• Factors that contributed to improvement or lack thereof
• Professional assessment of the client's condition

Examples:

"Client showed immediate reduction in upper trapezius tension following trigger point release. Reported pain decreased from 7/10 to 3/10 by session end. Improved cervical rotation noted bilaterally. Stress-related muscle holding patterns responded well to relaxation techniques."

"Lumbar mobility improved moderately with fingertips reaching upper shin level post-treatment. Client reported 50% reduction in muscle guarding sensation. Deep tissue work effectively addressed adhesions in erector spinae, though full resolution requires additional sessions."

4. P - Plan

This final section outlines your recommendations for future treatment and self-care.

Purpose: Establish clear next steps for continued progress and optimal outcomes.

Length: Keep this section concise and actionable, typically 2-3 sentences.

What to include:

• Frequency and focus of future sessions
• Specific techniques to emphasize
• Home care recommendations
• Referrals to other healthcare providers if needed

Examples:

"Recommend weekly sessions for 4 weeks focusing on upper body tension patterns. Will incorporate more trigger point therapy and stretching education. Client advised to apply heat therapy and practice neck stretches between sessions."

"Continue bi-weekly treatments targeting lumbar region with emphasis on myofascial release. Plan to progress to maintenance schedule once pain consistently below 3/10. Referred to physical therapy for strengthening exercises to prevent recurrence."

Complete SOAP Note Examples for Massage Therapists

Now let's look at three complete examples that bring all these components together.

Example 1: Lower Back Pain from Work Injury

Client: 38-year-old male, construction worker
Session Type: Therapeutic massage, second visit
Chief Complaint: Lower back pain from lifting injury

S – Subjective:

Client returns for follow-up treatment of lower back pain. Reports pain level has decreased from 8/10 to 5/10 since first session one week ago. States he can now sleep through the night without waking from back pain, which is "huge improvement." Pain still present when bending forward or lifting objects over 20 pounds. Describes pain as deep, aching sensation concentrated in lower lumbar region, occasionally radiating into right hip. Has been using ice packs as recommended and taking ibuprofen 400mg twice daily. Avoided heavy lifting at work this week per doctor's orders. Goal today is to continue reducing pain and increase flexibility for gradual return to full work duties. Denies numbness or tingling in legs. No bowel or bladder changes.

O – Objective:

Posture: Slight forward lean with reduced lumbar lordosis, favoring right side when standing
Range of Motion: Lumbar flexion limited to fingertips at knee level (improved from mid-thigh last week), extension limited to 10 degrees with guarding
Palpation: Moderate to severe tension in erector spinae L3-S1 bilaterally, more pronounced on right side. Trigger points identified in right quadratus lumborum and gluteus medius. Increased warmth and slight swelling noted in right lumbar paraspinals. Muscles less rigid than previous session.
Treatment: 60-minute therapeutic massage. Applied moist heat pack to lumbar region for 10 minutes pre-treatment. Performed gentle Swedish massage for warm-up, followed by deep tissue techniques to lumbar paraspinals, glutes, and hip flexors. Myofascial release to thoracolumbar fascia. Trigger point therapy to identified points using moderate pressure with 30-second holds. Client tolerated treatment well with some tenderness during trigger point work, rated discomfort 4/10.
Post-Treatment: Client demonstrated improved lumbar flexion to fingertips at upper shin level. Reported feeling "looser" and pain reduced to 3/10.

A – Assessment:

Client showing good progress in recovery from acute lower back strain. Significant improvement in pain levels, sleep quality, and range of motion since initial visit. Muscle tension decreased approximately 40% based on palpation findings. Trigger points in quadratus lumborum and gluteus medius contributing to referred hip pain - responded well to direct pressure techniques. Client's consistent use of home care recommendations (ice, anti-inflammatories, activity modification) supporting treatment outcomes. Guarding patterns beginning to release, suggesting decreased protective muscle spasm. Expect continued improvement with consistent treatment and gradual return to activity.

P – Plan:

Continue weekly therapeutic massage sessions for next 3 weeks, then reassess frequency. Will focus on deeper myofascial work as tissue tolerance improves. Next session will incorporate passive stretching for hip flexors and hamstrings. Instructed client on self-massage techniques using tennis ball for gluteus medius trigger points. Recommended continuing ice after work shifts and introducing gentle stretching routine (demonstrated cat-cow stretch and knee-to-chest stretch). Client to gradually increase activity level but continue avoiding lifting over 30 pounds for one more week. Follow up with primary care physician in one week as scheduled. Client to call if pain significantly increases or any neurological symptoms develop. Client verbalized understanding of home care plan and demonstrated correct stretching technique.

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Example 2: Chronic Neck and Shoulder Tension from Desk Work

Client: 45-year-old female, office manager
Session Type: Maintenance massage, regular client for 6 months
Chief Complaint: Routine session for ongoing neck and shoulder tension

S – Subjective:

Client presents for regular monthly massage. Reports overall stress level 6/10 this month, down from usual 7-8/10. Started new ergonomic setup at work three weeks ago with adjustable desk and monitor arm, which she feels is "helping a little." Still experiencing neck stiffness by end of workday, rated 5/10, especially on right side. Occasional tension headaches 1-2 times per week, usually late afternoon. Has been practicing stretches learned in previous sessions during lunch breaks "when I remember." Sleep quality good, 7-8 hours nightly. Taking yoga class once weekly for past month and enjoying it. No acute pain today, just "the usual tightness." Goals are stress relief and maintaining manageable tension levels. Denies any new injuries or concerns.

O – Objective:

Posture: Improved alignment compared to previous visits, less forward head posture noted (approximately 1 inch improvement). Right shoulder remains slightly elevated.
Range of Motion: Cervical rotation 75 degrees bilaterally (within normal limits), lateral flexion slightly limited on right side. Shoulder mobility full and pain-free.
Palpation: Mild to moderate tension in upper trapezius bilaterally, more pronounced on right. Upper cervical muscles moderately tight. Trigger points in right levator scapulae and bilateral suboccipitals, less reactive than in past sessions. No acute inflammation or muscle spasm present. Tissue quality improved with better hydration noted.
Treatment: 60-minute relaxation massage with therapeutic focus. Swedish massage techniques throughout full body with emphasis on neck, shoulders, and upper back (30 minutes). Used moderate pressure progressing to firm as tolerated. Trigger point therapy to identified points, each held 20-30 seconds. Incorporated passive stretching for neck and shoulders. Used lavender aromatherapy per client preference.
Client Response: Relaxed well during treatment, breathing deepened, fell asleep briefly during back work. Reported feeling "much lighter" post-treatment.

A – Assessment:

Regular client maintaining good baseline tension management through monthly massage and lifestyle modifications. Noticeable improvement in overall muscle tension compared to treatment initiation 6 months ago - trigger points less active and tissue quality improved. Ergonomic changes at work and yoga practice supporting therapeutic outcomes. Right-sided tension pattern persisting but less severe than previously. Client benefiting from combined approach of regular massage, self-care practices, and workplace modifications. Stress-related holding patterns continue but are more manageable with current treatment frequency. Client demonstrating good body awareness and engagement in self-care.

P – Plan:

Continue monthly 60-minute maintenance massage sessions at current frequency. Will alternate between full-body relaxation focus and targeted therapeutic work on neck/shoulders based on client's monthly stress levels. Encouraged client to maintain yoga practice and workplace stretching routine. Recommended increasing stretching frequency to twice daily - morning and afternoon at work. Provided reminder about proper workstation posture: monitor at eye level, keyboard at elbow height, feet flat on floor. Suggested exploring meditation or mindfulness apps to support stress management between sessions. Client may benefit from increasing to bi-weekly sessions during particularly stressful work periods (budget season in 2 months). Next appointment scheduled in 4 weeks. Client pleased with progress and committed to continuing self-care practices.

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Example 3: Sports Massage for Marathon Training

Client: 28-year-old female, amateur runner
Session Type: Sports massage, pre-event
Chief Complaint: Muscle tightness during marathon training

S – Subjective:

Client presents for sports massage two weeks before first marathon. Training has been going well overall but reports increased muscle tightness and fatigue over past 3 weeks during training taper. Legs feel "heavy" especially during warm-up of runs. Left IT band area occasionally uncomfortable (3/10) during runs longer than 10 miles, though pain resolves with walking. Right calf feels "tight" even after stretching and foam rolling. No acute injuries or sharp pains. Completed 20-mile training run 10 days ago with some soreness that resolved in 3 days. Currently averaging 30-40 miles weekly, down from 50 miles during peak training. Sleep 8 hours nightly. Hydration and nutrition plan in place per running coach. Goal today is to reduce muscle tightness, improve recovery, and prepare body for race day. Feeling nervous but excited about upcoming race.

O – Objective:

Posture: Good overall alignment, slight internal rotation of right hip noted when standing
Gait: Observed walking gait - minimal abnormalities, slight favoring of left leg during weight shift
Range of Motion: Hip flexion and extension full bilaterally, hamstring flexibility moderate (fingertips to mid-shin), left IT band tighter with Ober's test compared to right. Ankle dorsiflexion slightly limited on right.
Palpation: Bilateral quadriceps showing moderate tension, left vastus lateralis particularly tight. IT bands firm bilaterally, left more so. Right gastrocnemius and soleus significantly tight with multiple small adhesions palpated. Hamstrings moderately tight bilaterally. Hip flexors shortened but no trigger points. Glutes firm but responsive to pressure.
Treatment: 90-minute sports massage focusing on lower body. Used combination of techniques: Swedish massage for warm-up, deep tissue for adhesion release, myofascial release for IT bands and plantar fascia, active and passive stretching. Applied moderate to firm pressure throughout. Worked systematically: feet and calves (20 min), hamstrings and IT bands (25 min), quadriceps and hip flexors (20 min), glutes and piriformis (15 min), final full-leg integration (10 min).
Client Response: Tolerated deeper pressure well, reported "good pain" during IT band and calf work. No excessive soreness or bruising noted.

A – Assessment:

Well-conditioned athlete experiencing normal training-related muscle tightness during taper phase before first marathon. Muscle tension patterns consistent with high-mileage running: tight hip flexors from repetitive hip flexion, IT band tension from lateral hip stability demands, calf tightness from push-off phase. Right calf showing most restriction with adhesions likely from accumulated micro-trauma during training. Left IT band tightness may be contributing to reported discomfort during long runs. No acute injuries or inflammatory conditions present. Tissue quality good overall with normal response to treatment. Client's taper strategy and reduced mileage appropriate for recovery. Good candidate for sports massage protocols to optimize performance and prevent injury on race day.

P – Plan:

Scheduled follow-up sports massage 3 days before marathon (11 days from today) - will use lighter pressure for final tune-up and focus on promoting relaxation and circulation rather than deep tissue work. Instructed client on self-care between now and race: daily foam rolling for IT bands, quads, and calves (10 minutes); dynamic stretching before runs; static stretching after runs holding each stretch 30 seconds; ice bath or cold water immersion for legs after any runs over 8 miles. Recommended continuing current taper plan and avoiding any new stretching or strengthening exercises. Emphasized importance of rest and sleep during final two weeks. Discussed race day warm-up routine: 10-minute easy jog, dynamic leg swings, gradual acceleration. Advised against any massage in final 48 hours before race to avoid any muscle soreness that could impact performance. Encouraged client to trust training and provided reassurance about normal pre-race jitters. Client to contact if any acute pain develops before next session. Post-race recovery massage recommended 3-5 days after marathon to address any soreness and promote muscle recovery. Client expressed feeling more relaxed and confident about race preparation.

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Additional Tips for Massage Therapy SOAP Notes

Be Specific: Use anatomical terms and specific massage techniques rather than vague descriptions. "Applied trigger point therapy to right upper trapezius" beats "worked on shoulder area."

Include Safety Information: Document any contraindications, precautions, or adverse reactions. If client mentioned any health conditions during intake, note that you adjusted treatment accordingly.

Measure Progress: Use objective measures like pain scales, range of motion, and functional improvements to track progress over time. Numbers tell a better story than "client feels better."

Stay Professional: Maintain professional language while being thorough in your documentation. These notes could end up in court or with insurance companies.

Legal Protection: Remember that SOAP notes serve as legal documents that may be reviewed by insurance companies or in legal proceedings. If you didn't document it, legally it didn't happen.

Document Home Care: Always record what self-care instructions you provided. If client doesn't follow through and gets worse, your documentation shows you did your job.

Implementing structured SOAP notes in your massage therapy practice ensures comprehensive client care, demonstrates professional competency, and provides valuable information for treatment planning and progress tracking.