SOAP note charting is an easy, popular and effective way to keep records, including for the practice of massage. SOAP is an acronym for:
A SOAP note provides a narrative of the client's issues. The massage therapist records how they will address the client's issues with massage therapy application with a well formulated plan after assessment.
The following is a SOAP note example for massage therapy record keeping purposes. In this SOAP note example, we will review how to record a client's massage therapy treatment to address a client's pain:
Subjective: here are some examples of questions for a client who seeks pain relief. A massage therapists can ask as little or many of these questions as they wish - the more information, the better directed a practitioner will be to addressing a client's needs:
Onset: When did their pain start?
Location: Where is their pain?
Duration: How long is the pain a problem?
Alleviating Factors: Is there anything that relieves the pain?
Aggravating Factors: What makes the pain worse?
Chronology: Better or worse since onset? Is pain variable, constant, etc.?
Quality: Is the pain sharp, stabbing, dull, etc.?
Additional Symptoms: Is there any numbness, tingling, loss of coordination?
Treatment: What else has been done to address the pain?
Temporal Pattern: Is the pain every morning, all day, etc.?
Severity (think VAS which readers can learn more about in our school blog): A scale of 1-10 can be used with 1 being almost no pain and 10 being intolerable, then the client can choose their # for the pain that they experience throughout the day, or when pressure is applied during the massage.
Objective: the bodyworker will document objective, repeatable, and traceable facts about the client’s status. This includes:
- Client’s personal statistics
- Palpable tissue changes (softer, more pliable, etc.)
- Range of motion increases/decreases (use goniometer)
- Observed abnormalities
- Anything medically remarkable that would be relevant to the:
- Client’s health
- Bodywork contraindications
Assessment: the bodyworker’s collective assessment of the client’s body (and goals) from the subjective and objective information.
Plan: describes what the bodyworker will perform for the client. This can include the “Treatment Plan” as described earlier in this course, including:
- Number of minimum appointments needed to achieve goals
- Length of appointments needed to achieve goals
- Costs of Individual Appointments as recommended in the treatment plan
- Areas to be worked on (on the client’s body)
- Modalities to use in different areas of the client’s body
- Physical Address of Where Bodywork Will Occur
- Set Goals – the goals the client wants to achieve through bodywork
- Consent or Agreement
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