SOAP Notes for Massage
(Subjective Objective Assessment Plan)
for Bodyworkers/Massage Therapists
The purpose of SOAP charting is
to record the client's condition and progress that occurs in each session
of bodywork/massage. It is usually required for sessions that will
be paid for by an insurance company, whether it is a PIP (auto mobile),
L&I (Labor and Industries) or Major Medical. Your records may
be requested by physicians to keep them updated as to the condition of
the client or by lawyers who need them as records of the clients injury
and progress. Either way, it is important to keep the clients charts
updated and complete.
Subjective: The client's subjective
complaints and symptoms that are in the clients own words or may have been
discussed by the prescribing physician. This includes all the things
the client tells you about how they are feeling, past history, present
symptoms, limitations in their lives due to the injury, what makes them
feel better or worse, and details about the initial onset of the problem
or injury. It is often helpful to ask the client to rate their pain
or discomfort on a level 1-10 with 10 being the worst. If you do
this each time, you will be able to see improvements or setbacks.
Ask specific questions as to the location,
intensity, duration and frequency of the pain or discomfort. Have the client
point to the specific area on their body or body chart. Ask how painful
is it? How long have they had it? Hours? Weeks? Months? Longer? Has
it been worse or better? What makes it worse or better? How often do they
get it? Every day? Once a week?
Asking specific questions will lead to
a clearer picture of the problem/injury you are treating.
Objective: This is the observations
of the practitioner and what techniques were done during the session. This
includes visual observations and what you feel in the body of the client.
Include things you observe about the clients posture, patterns, movement,
weakness, level of tension in the tissues, spasms in muscles, joint movement,
color/temperature of skin and breathing patterns.
You can also test the range of motion
in different areas and keep track of their improvement or changing patterns.
Some common findings are defined below:
Hypertonicity: involuntarily tight
or contracted muscle; excess muscle tone; the tension of the resting muscle
is unusually high.
Spasm: involuntary contraction
of a muscle as a protective response to an injury or trauma.
Trigger point: specific point that
refers pain
Adhesion/scar tissue: the resulting
tissue from the wound healing process causing a restriction in resiliency
of the tissue
Assessment: As most bodyworkers
or massage therapists are not allowed to diagnose conditions, this is to
report the immediate results of the session. At the end of the session
reanalyze the posture and range of motion. Make notes on any changes
in symptoms. Indicate how much change happened- mild, moderate or
significant change. Use as many descriptive words as possible.
Most insurance companies will take this
information into consideration when paying for the treatment. This
is what is telling them if the client is getting better and is the treatment
worth it.
Plan: Suggest a treatment frequency
and things that need to be addressed in the future. Include any self
care instructions you gave to the client, special requests by the client,
or reminders for the next session.
See also: What
should SOAP notes say?
Functional
outcomes reporting
Insurance
Billing - complete information on how to bill
insurance companies for massage therapy services with links to forms, sample
chart notes, and more.
