The Best Way to Write Soap Notes For Massage Therapist

Soap Notes For Massage Therapist | Quick Guide with AI

You're a massage therapist and the last thing you want to think about is documentation. However, every single day, you need to document. It's important for progress tracking, providing information to insurance companies, and even other professionals.

You simply can't ignore it. So how do you go about it?

Quick Tip

Head over to soapnotes.doctor.

Use the mic to listen to your session.

Soapnotes.doctor will securely transcribe and generate SOAP notes tailored to your session.

You can add:

1. Edit
2. Add context
3. Review before finalyzing

Read more about it.

Longer Version…

Let's dive in.

SOAP Notes in a Jiffy

Some time before the 1960s, medical notes used to be more like jotter notes. You pick and write in whatever format comes to your head. Maybe you put in dates some days and on other days, forget entirely that you ever wrote dates.

This happened until Dr. Lawrence Weed decided to weed that out (no pun intended). He introduced them in the late 1960s as part of his broader system called the Problem-Oriented Medical Record (POMR).

The goal was to provide a systematic way for healthcare providers to document encounters so that any clinician could pick up the record and clearly understand the patient's condition, the provider's thinking, and the treatment plan.

Dr. Lawrence Weed introduced SOAP notes:

• S (Subjective): What the patient reports (symptoms, history, complaints).
• O (Objective): What the clinician observes or measures (vitals, exam findings, test results).
• A (Assessment): The provider's interpretation/diagnosis based on S + O.
• P (Plan): The treatment, further tests, or follow-up actions.

This framework quickly spread beyond medicine into nursing, behavioral health, physical therapy, and other healthcare fields because of how organized and versatile it is.

Today we're writing an article on how to write them for massage therapists.

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

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

Use soapnotes.doctor

I'll pick soapnotes.doctor every day since it's cleaner, never superfluous, accurate, secure and most importantly faster.

Here's how to speed run the whole process:

1. Head over to soapnotes.doctor to get started. Finish 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 ever feel that would be better).
3. Wait 1-3 minutes.
4. Review and save.

The beauty of this is the flexibility it comes with. It's perfect. You could add context if you ever want. Tweak it. Edit. Review and export to your respective EMR.

And it's that simple. You're done with SOAP notes with all details for a massage therapist.

Write Them Manually

Like everybody once did, you write manually.

Here's my guide to writing a good SOAP note, based on the provided source:

The trick is to never see SOAP Notes as a narrative job.

1. S - Subjective

This section captures your client's perspective and sets the foundation for the entire session.

Here, you gather information before beginning any hands-on work.

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

This section contains 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."

Additional Tips for Massage Therapy SOAP Notes

Be Specific: Use anatomical terms and specific massage techniques rather than vague descriptions.

Include Safety Information: Document any contraindications, precautions, or adverse reactions.

Measure Progress: Use objective measures like pain scales, range of motion, and functional improvements to track progress over time.

Stay Professional: Maintain professional language while being thorough in your documentation.

Legal Protection: Remember that SOAP notes serve as legal documents that may be reviewed by insurance companies or in legal proceedings.

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.