Writing treatment notes is one of the routine activities that massage therapists do every day. The most common form that therapists use to document their client sessions is the SOAP note.
What are SOAP notes? A SOAP note is a documentation format that massage therapists and other healthcare workers use to document client encounters. SOAP is an acronym that stands for subjective, objective, assessment and plan.
In this post, I’ll discuss what information goes in each section of the SOAP note. I also have some tips to help you write your SOAP notes faster and better. The last section of this post talks about what you need to know about SOAP notes for the MBLEx.
Let’s take a closer look at the SOAP note.
What are SOAP notes?
SOAP notes are how massage therapists and other healthcare workers document their client sessions. The SOAP format provides clinicians an organized structure to document the most important parts of a client / patient encounter.
SOAP notes are a format for medical charting that have been around since the 1960’s and it is currently one of the most widely used methods of documenting massage therapy sessions.
The basic format of the note follows the SOAP acronym:
S = Subjective. This section includes information that the client tells you (chief complaint, symptoms, etc.) in his or her own words.
O = Objective. Includes your clinical findings and observable data (posture, muscle tone, ROM, temperature, tenderness, swelling, etc.)
A = Assessment. Your assessment or analysis of client response to treatment and progress towards goals.
P = Plan. Includes your plan for their next visit, and any instructions that you gave the client.
You will likely see dozens of variations of this SOAP note format, and different ideas about what information goes in each section. Some therapists use the SOAP note to document initial client evaluation. However from my experience, a separate eval form works better for that.
The SOAP note format is not without its limitations. The “S-O-A-P” is vague and leaves a lot open to interpretation regarding where certain information should be placed. Some of the information that you need to document doesn’t clearly fit into any section. There is also inconsistency in how it is taught from textbook to textbook, from teacher to teacher, and even between professional agencies.
For example, the massage treatment you provide today usually goes in the objective section, even though it is very different information than objective data. The SOAP note examples provided by ABMP do it this way.
However other sources (including the AMTA) consider the “A” in SOAP to mean Assessment and Application, indicating this is where you include details of your massage treatment used today.
There is also not an obvious place to address goals or write new goals. Progress towards goals can be subjective if the goal is related to pain. The progress may also be observed objectively, if it is a ROM or posture goal. And all of this data is analyzed in the Assessment process.
You may be wondering…
Are SOAP notes required in massage therapy? The answer is….sometimes. It depends on where you work. Generally, the more clinical the setting, the more likely you are to be required to document your treatments. However, even many spa settings or offices that primarily give relaxation type massages will require you to at least write a visit note. Typically there are no treatment documentation requirements for short chair massages like at an onsite or promotional event. It would be impractical and pointless to write SOAP notes for 10-minute chair massages with clients that you will probably not see again.
But even if you have your own cash based massage practice with no boss telling you that you have to write a SOAP note for every treatment, it is still best practice to document your work.
Why is documenting important for massage therapists?
Documenting client encounters is important for massage therapists for 4 main reasons:
- To track progress. SOAP notes create a treatment record so you can track the client’s progress towards their therapy goals. This applies if you are a solo massage therapist, or if you are working for a supervising clinician like a physical therapist, chiropractor or medical doctor. Whoever is supervising the treatment plan needs to know what you have been working on with the patient, and what their response has been.
- To communicate with other therapists. This is how we communicate with other massage therapists. For example, if you are working at a multi-therapist clinic and another massage therapist needs to see the client, that therapist will know what you have been working on and what the plan was for this treatment, if there was accurate documentation.
- For future reference. Good documentation helps you to accurately remember the client’s previous visit, and the plan that you intended for this visit. It may be months or years before you see the client again, so make sure your note is well-written.
- Liability protection. Documenting your massage interventions can potentially help to mitigate risk in case a client accuses you of causing an injury by doing some thing you did not do.
If it’s not in writing, then it didn’t happen.
There are other reasons that call for accurate documentation of client encounters. Massage therapists who do insurance billing will need to have documentation that shows what the impairments and functional limitations were, what treatments were provided, and what progress was made towards therapy goals.
Subjective section of a SOAP note
This section contains information that the client tells you. It is the client’s self-report. Symptoms go in this section. The subjective section should be in a detailed, narrative format. You can also include any relevant direct quotes from the client here (use quotation marks around the client’s statement).
Here’s what could go in the subjective area of a SOAP note:
- History of present illness, injury or condition
- Pt. report of medication changes or new injuries
- Client’s chief complaint (pain, etc.)
- Client stated goals
- The client’s subjective response to the previous treatment(s)
- How they feel about their progress
- Client’s stated opinions about relevant topics (massage treatments, progress, etc.)
Even though pain is subjective, try to objectify it is as much as possible. You can use the Numeric Pain Rating Scale (NPRS) or the Visual Analog Scale (VAS) to rate the intensity of the client’s pain from 0-10.
Also, try to get details about the client’s pain, since this can help you determine a potential origin (but not diagnose) and monitor the effectiveness of your treatments. Find out the location, duration, onset, character or description, if it radiates/refers, what makes it better or worse, etc.
Common errors that massage therapists make when writing the subjective section of a SOAP note:
- Passing judgement on a client. For example, “Client is exaggerating her pain level again”.
- Documenting irrelevant information, like “Client complained about the football team losing”. While it is good to keep track of client interests for marketing purposes, this information does not belong in the SOAP note.
What goes in the Objective section of a SOAP note?
The objective section of the SOAP note contains information that you gather through observation, palpation, or performing reassessment tests. This could include measuring range of motion (ROM), observing how a client walks, posture, affect, muscle tone, skin lesions, movement abnormalities, etc.
These are things that any other massage therapist would be able to observe if they were seeing the client. The objective section is often the most confusing section of SOAP notes for massage therapists.
What could go in the objective area of a SOAP note?
- Observations from assessment or reassessment, e.g. ROM, posture, etc.
- Progress towards goals, based on objective findings
- Details of specific treatments/modalities provided today. Include: position, techniques used, duration of treatment, areas of focus, equipment used (moist heat, cold pack, T-bar, essential oils, etc.)
- Observable or palpable response to today’s massage treatment
Common errors that massage therapists make in the objective section of a SOAP note:
- Vague information about treatments that were performed.
- Including value judgements, bias or personal opinions
- Diagnosing based on observations. For example, “Client demonstrated decreased left shoulder abduction ROM, indicating a frozen shoulder.” Or writing this when a client does not have a diagnosis of muscle strain from physician: “Client has pain at lower back due to muscle strain”. A lower back muscle strain is a medical diagnosis (ICD-10 code: S39.012s).
Do what you write and write what you do.
This is where you describe the client’s response to your massage and bodywork treatment(s). The assessment section is the most important and most closely scrutinized section of the SOAP note when billing an insurance company. They want to know if the client is getting better and making progress towards functional goals, and if they should reimburse for this treatment.
What could go in the assessment area of a SOAP note?
- Therapist’s assessment (clinical opinion) about the client’s progress towards treatment goals
- How the patient responded to the treatment today
- Any adverse reactions to today’s treatment
- Client change in status
- Some sources say that today’s treatment details goes in the assessment section
Common errors that massage therapists make in the Assessment section of a SOAP note:
- Vague assessment such as “Tolerated treatment well”.
- Including a personal opinion or judgement
The plan area of a SOAP note is where you outline what you intend to do during future sessions.
What typically goes in the plan section of SOAP notes?
- Treatment plan for the following visit(s)
- Frequency and duration recommendations (1x/wk x 4 weeks)
- Reminders to reassess something next visit
- Client’s self-care plan (stretches, exercises, heat or cold recommendations, etc.)
A common error that massage therapists make in the plan section of a SOAP note is writing a vague plan like “Continue treatment”.
SOAP note example for massage therapy
Here is a SOAP note example for a massage session, to further demonstrate what kind of information goes in each section. Every massage treatment note should also include: client name, date & time, therapist name, title and signature.
Subjective: Client stated that it has been about 1 month since her last massage. C/O 2 weeks of increased tension at upper back and neck, stating, “I’ve been working a lot more on my computer, and have had a headache for two days.” Currently 3/10 dull, aching pain at right trapezius area. “I want a relaxation massage with focus on neck and shoulders.”
Objective: Point tenderness at right superior angle of scapula. Gross BUE and cervical strength and ROM WNL. Provided full-body Swedish massage. TrPs at right upper traps and levator scapula. DT, MFR and TRP work at right upper traps and suboccipitals, with TrP referring to ipsilateral temporal region, reproducing Pt. headache. Provided client education on correct sitting posture; issued handout with diagram and instructions on improving workspace ergonomics. Instructed client in exercises: trapezius stretch in supine, scapular retraction and chin tucks in sitting. All treatment kept within Pt. tolerated limits.
Assessment: Pt. reported 0/10 pain after treatment. Good understanding and return demonstration of HEP of stretches and postural exercises. Trigger points responded well to TRP therapy; decreased tenderness and referral of symptoms after treatment. No adverse reactions from treatment.
Plan: Continue DT and TRP work upper back and neck as needed. Reassess sitting posture and HEP technique at next visit. Follow-up with client on implementing recommended improvements in office workspace ergonomics.
Abbreviations for massage therapy SOAP notes
Using abbreviations can help speed up the documenting process. But it can cause confusion if not done correctly. Be consistent and use only standard abbreviations. Some facilities will have their own requirements about what abbreviations to use and which ones to avoid.
Also, if you’re not sure if you are using the correct abbreviation, then its best to just spell it out.
When in doubt, spell it out.
Documentation should always be clear. Never sacrifice clarity for brevity. Avoid using any ambiguous abbreviation that may be misunderstood by someone else. If you do insurance billing, then the claims rep is most likely not a clinician and may not know what some of the abbreviations or jargon means.
*Pro tip: Be aware that different settings have their own set of abbreviations. For example, “abs” may mean abdominals in massage therapy. But can also be an abbreviation for abdominal surgery, acute brain syndrome, at bed side, absent, absorption, or admitting blood sugar. Another example is “Fx”, which usually refers to friction for massage therapists. But in the rest of the medical world, it is an abbreviation for fracture. So if you are working in a medical setting or receiving referrals from other clinicians, make sure everyone is on the same page about what the abbreviations stand for.
Here are some of the most common abbreviations that massage therapists use when documenting in a SOAP note:
1° = primary
2° = secondary to
ā = before
AA = active assisted
Abd = abduction
Add = adduction
Amb = ambulate
ASIS = anterior superior iliac spine
BLE = bilateral lower extremities
C-spine = cervical spine
C/O = complains of
CC = chief complaint
CL = client
Cont. = continue
CST = craniosacral therapy
CT = connective tissue
D/C = discontinue or discharge
DJD = degenerative joint disease
d/t = due to
DT = deep tissue
Dx = diagnosis
Eff = effleurage
Fx = friction
HA = headache
HEP = home exercise program
Hx = history
LTG = long-term goals
Med = medial
MH = moist heat
Palp = palpation
Pet = petrissage
PMH or PMHx = past medical history
PT = physical therapy
ROM = range of motion
s/p = status post (after)
SCM = sternocleidomastoid
SL = side lying
STG = short-term goals
Sx = symptoms
TP or TrP = trigger point
Tx = treatment
w/o = without
WLF = within functional level
WNL = within normal level
XFF = cross fiber friction
Tips for effective SOAP note documentation
It is important for all massage therapists, whether working as an employee or self-employed, to be able to write an effective SOAP note. And in most cases, it needs to be written fairly quickly. If you see 5 clients per day, you don’t want to spend 15-20 minutes per note.
Write the note immediately after the treatment. It will be faster for you to write your SOAP note while the information is fresh in your head. In fact, I would recommend starting the note while the client is getting on the table. You can get most of the subjective section, and some of the objective section completed in this time. It’s no fun to get to the end of the day and still have 6 SOAP notes that you haven’t even started. When this happens, it is very difficult to accurately remember what each client said, and the details of each treatment.
Write it all down. Don’t write a thin or vague SOAP note while thinking “I’ll remember next time what I did”. The point of documenting is so that you don’t have to remember the details. Don’t use your brain as a filing cabinet. It may be months before you see this client again. What happens when they come back and say, “I love what you did last time, it helped a lot. Do that again.”? When you are able to recall the details about their previous treatment (after looking at your old SOAP note), you will look like a genius! Plus it will make the client feel special and more important when you remember your previous encounter with them.
Keep your notes brief. This may sound like I’m contradicting the previous tip, but keep your notes concise. It is good to be concise (but not overly concise) and exclude unnecessary content. But be sure to include everything that is important.
Write neatly. If you write your SOAP notes by hand, write neatly so that you or another therapist can read your writing. If this is a challenge for you, there are many computerized documentation systems to help with this and streamline your documentation. Use black (preferred) or blue ink.
Write with a purpose. When writing a SOAP note, remember the purpose of the note rather than just writing it to get it over with. When you write deliberately, the note will be more useful when you or someone else needs to read it.
Avoid overuse of abbreviations. Using too many abbreviations can make reading the SOAP note confusing, especially if the abbreviations are not standard. Also avoid generalizations such as “good” or “large”. Be as specific as needed.
SOAP notes for the MBLEx
By now you have a solid understanding of what SOAP notes are used for, and what kind of information to write in each section. This should be everything you need to know about SOAP notes for the massage exam.
Here are a few key concepts about SOAP notes and written data collection to be sure to know for the MBLEx (all covered in the post):
- What information belongs in a treatment note?
- Why is it important to document client sessions?
- Why is it important to measure and track progress towards goals?
- What is the difference between subjective and objective data
- You should include your clinical opinion (assessment) in your documentation, but not your personal opinion or judgement.
When do I NOT need to document massage treatments?
There are few times when massage therapists do not need to document. However, if you are working an onsite massage event, documenting each client interaction is not practical or functional. Doing a quick health and safety screen and getting informed consent is still best practice though.
Are SOAP notes legal documents?
Yes. SOAP notes and other clinical documentation are considered to be legal documents. These are considered to be complete records of the client encounter. So document everything that needs to be included.
*I’m not a lawyer. Nothing in this blog post is meant to be medical or legal advice.