Massage therapists and other health care professionals often use SOAP notes to document clients' health records. SOAP notes (an acronym for subjective, objective, assessment, and plan) have become a standardized form of note-taking and are critically important for a variety reasons.
Why are they so important? We are happy you asked.
In this article, we'll cover some common ways to document your SOAP notes in a massage therapy setting, as well as the role of client intake forms in your practice.
SOAP Notes For Massage Therapy
SOAP notes give massage therapists a structured approach to help facilitate the most beneficial massage sessions for their clients.
Massage therapists know that every minute counts, so creating some sort of outline for your massage sessions will help utilize your time and your client’s time in the most effective way.
Documenting SOAP notes can be an invaluable tool when dealing with insurance companies and it can also improve communication between you and your clients.
What are Massage Therapy SOAP Notes?
SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. Here's what they mean:
This is where you document your client’s complaints, such as the location of pain, the intensity, frequency, etc. It's considered "subjective" because it could be up for interpretation.
One client describing something that "really hurts" could be what another client calls "a little sore."
This is what information the massage therapist is able to gather through visual assessment, palpitation, and testing through massage. It's considered objective, because any other massage therapist should be able to get the same or similar ideas.
For example, you could tell if a certain muscle group was tighter on one side than the other. Or through visual assessment, you note a hunched posture on a client.
These are the functions and outcomes of the session. Here you can also document any limitations that your client may be experiencing like limited range of motion or lack of flexibility. The assessment is also where you give your educated reasoning behind the subjective and objective sections of your notes.
This is the course of treatment of your current session and recommended treatments for the future.
Are SOAP Notes Required in Massage Therapy?
It's important to note that there will be instances when SOAP notes are necessary and times when they are not. Be sure to consider your company’s standards, rules, and regulations so that you can be sure to meet their expectations.
Not all companies will require you to document SOAP notes in the same way.
For example, when giving five minute chair massages at a charity event, you may not need to document SOAP notes. Short massage sessions like the one mentioned in this example may not be conducive for the work environment that you are in.
Additionally, the level of work being done in shorter massage sessions (such as a chair massage) aren't usually enough to warrant any documentation.
As a good rule of thumb it is typically better to record SOAP notes if you are completing longer massage sessions on a client that you will likely see again for further care.
3 Tips for Effective SOAP Notes
So now you know why SOAP notes are important and when to use them, but how can you make your SOAP notes incredible?
1. Keep them straight to the point.
Often SOAP notes need to be recorded in a relatively quick manner as massage therapists may have little down time in between sessions to view/write these notes. Keep them brief, but include all pertinent information and try your best not to use any unnecessary words.
2) Write neatly.
You may be able to read your own handwriting, but this will be especially helpful if your client visits others massage therapists so that they can pick up where you left off.
3) Use universal abbreviations.
This may vary depending upon your workplace, but in general, there a fixed set of abbreviations that are well understood and recognized by massage therapists everywhere. Here are some common ones:
Massage Therapy Client Intake Forms
At the beginning of a massage, you or your company may request that your client fills out a general client intake form.
These intake forms can be very useful to you as a therapist, because they will tell you who your client is, conditions they may have presently, and what their previous history is.
Here's a little more about what client intake do.
Client Intake Forms Provide Consent
Sometimes these intake forms will provide a list of specific areas that your client needs to check off in order to provide consent for you to work on them. These are usually more sensitive places where not everyone feels comfortable being worked on.
Some examples of areas that require consent are the pectoral muscles, face, feet, scalp, glutes, and abdomen.
By including a section like this on the intake form, it can help you easily identify areas of comfort/ discomfort for your client during a massage.
Massage Client Medical History
Additionally, there may be a section of your client intake form that asks your clients to list any sort of medical conditions that they may have or medications they may be taking.
Another common question on these intake forms will ask your client if they are pregnant. This is important for you to know, because some medical conditions (including pregnancy) can contraindicate certain types of massage or any massage at all.
A case where all massage may be contraindicated would be if your client recently was in a car accident or just had a surgery.
If a client comes in and says that they want work on their neck, but on their intake form you see that they were just injured yesterday, you should not definitely not work on them. Knowing this can prevent your client from getting further injured.
Massage Therapist Protection
One final example where this could be especially important to protect you would be if your client lists that they have poison ivy or some other sort of contagious skin condition.
While this one may seem obvious, these are still important things to look for and ask about on your intake form. Failing to do so could result in you being sick and unable to work on other clients.
This shows how SOAP notes helps protect not only the client but protect the massage therapist too.
However, medical conditions are not the only way that documentation can help you. Occasionally discrepancies between massage therapist and clients about what takes place in the massage room do occur.
While this is an unfortunate scenario, and we do hope that all massage therapists are conducting themselves in an ethical manner, if a client says, for example, that you did not drape their legs properly but your SOAP notes show that your client only requested work on their neck, and you only performed an upper body massage, SOAP notes will demonstrate this.
If your massage insurance company ever needs to step in to handle a dispute, your SOAP notes will be referenced.