SOAP Notes for Massage 

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.

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