Taking massage therapy SOAP notes is one of the best ways to track your clients’ progress and assess a patient’s condition. They’re also a useful communication tool.
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- What Are Soap Notes For Massage Therapy?
- Why Are Massage Therapy SOAP Notes Important
- How To Write Good Massage Therapy SOAP Notes?
- SOAP Note Example For Massage Therapy
- Massage SOAP Note Templates
What Are Soap Notes For Massage Therapy?
You may be asking “What does SOAP stand for in massage therapy?” and “Are SOAP notes required for massage therapy?”
What’s in a SOAP note? A lot, actually.
Let’s start by going over the SOAP format and what each part contains.
SOAP stands for Subjective, Objective, Assessment and Plan. Massage therapists use client SOAP notes when filling out their intake forms, and then continue taking notes during client visits.
These notes help you a massage therapist to record your assessment of things like a client’s pain level, range of motion, stiffness and any other complaints. Then, you can come up with a treatment plan and track their progress and any changes.
What are the four parts of a SOAP note and how do I use them?
Good question. Here’s an overview of the different SOAP note sections and their functions.
The Subjective component includes the client’s description of their chief complaint (including the pain scale), along with any other symptoms they describe. Make sure to write the subjective section in the client’s own words.
The Objective component of the notes includes objective data and your own clinical findings like tissue heat, point tenderness, posture and response to motion tests. Since the objective section is purely clinical, make sure to be as specific as possible here.
The Assessment section is where you record the client’s response to treatment and progress you’re making towards the treatment goals.
What should be included in a SOAP note assessment? Make sure to include your own assessment, the patient’s response to any treatments, any precautions you took (including for allergies or contraindications) and any changes in their status during and immediately after the session.
Plan is where you record your plan for their subsequent visit, along with any self care instructions you’ve provided the client with.
Other healthcare professionals also do this routinely, too.
So, are massage therapists required to keep SOAP notes?
The short answer is that it’s complicated. Not everyone may need to take them, depending on whether your practice is therapeutic or purely for relaxation, but it’s still a best practice and well written massage therapy notes will make the next visit more productive.
Let’s take a closer look.
Why Are Massage Therapy SOAP Notes Important
Note taking helps both clients and massage therapists, and massage SOAP notes are necessary for several reasons:
Massage notes will track progress and record your treatment plan. This is important whether you’re working with other massage therapists or operating solo in a spa or clinic. You’ll want to provide other health care providers with a record when necessary, too. Make sure to include the client name as well as the therapist they saw each time.
Having a detailed medical history is important for not only your current treatment plan, but also as a reference for any future interventions your clients might receive. If the client’s condition or pain level changes between visits or their next treatment is weeks away, you’ll have a reference point. Including visual markers can help with this.
Massage SOAP notes make it easy to communicate with other massage therapists and ensure that everyone has access to the same documentation. If a client books with someone else at your spa during their next visit, the other massage therapist will see your massage chart notes and understand what you’ve been working on and why.
If a client claims to have been injured during or because of their last visit, having this record of your massage session can go a long way towards minimizing your own risks. These may also be required by insurance billing agencies.
So, do massage therapists have to take SOAP notes? Not necessarily, but it’s definitely a good idea.
How To Write Good Massage Therapy SOAP Notes?
As you can see, effective SOAP notes will lead to better massage treatments. Since these are treated as medical documents by the American Massage Therapy Association and other care providers, it’s important to document everything accurately.
Let’s look at what you can do to write better SOAP notes.
Write any SOAP notes required as soon as possible after each treatment. This will make things less time consuming since the last session is still fresh in your mind.
Use the same format and language for each client note for easy reference and follow up on what you wrote in a previous note. If, for example, you wrote that “Patient reported 2/10 pain” last time, make sure to follow up and document their current level.
When taking SOAP notes, massage therapy professionals should keep their purpose in mind and focus on deliberately documenting information, while avoiding irrelevant details or passing any judgements.
You might take note of the fact that “Client injured their left wrist playing hockey” but would not write “Client’s hockey team lost, again.”
Write neatly so that it’s easy for you and other therapists to read later, using appropriate medical terminology or acronyms as needed. If it’s hard to get things done neatly and quickly, consider using massage therapy software with SOAP notes to help you.
Brief and Specific
Include everything necessary, but try your best to be concise and specific in your documentation. This will save time and make it easier for others to read, later.
Avoid being too general by saying things like “Client responded well to treatment”, since this makes it hard to draw conclusions about what was successful or not.
Cohesive with Acronyms
Use acronyms where appropriate to record the short form, but remember that not all medical professionals use the same abbreviations- you’ll want to be careful with this. If you use a certain abbreviation or acronym, use it consistently and try not to switch between them.
Here’s an example of when abbreviations for massage therapy SOAP notes could cause confusion:
You may write “Client reported a feeling of tightness in abd” (In this case, “abd” means “abductor” and refers to a specific muscle group, but a doctor would likely interpret it as “abdomen”).
Use Massage Therapy Software
Massage therapy SOAP notes software can go a long way towards saving time and making the whole process easier.
Using software with electronic SOAP notes, massage therapy professionals can quickly create secure and HIPAA compliant notes and connect them to each client’s records. Digital SOAP notes eliminate a lot of human error and are easy to read.
You can also use the software to block off sections of time between clients to write everything down, using time efficiently.
In fact, when it comes to massage therapy, management software can do a lot to boost your business and save you time and money.
Not only can you view your schedule, set your availability and allow clients to book online, but you can send automated confirmations and reminders to reduce late arrivals and no shows.
You can use the software to view key business data like your busiest days/times and popular services. You’ll also be able to track your inventory levels and reorder supplies quickly. What’s not to like?
We recommend you to check out our post Massage Therapist Job Description.
SOAP Note Example For Massage Therapy
Here’s a typical example of massage therapy SOAP notes:
Client Name: J. Smith
Date/Time: August 18th, 2022/ 12:30pm
Length of Session: 1 Hour
Subjective: It’s been 1 month since the client’s last session. His chief complaint was pain and stiffness in lower back, stating that it began one week ago after he lifted several boxes of books at home. He reported a pain level of 3 on a scale of 1-10 and says that pain improves when lying down. Client mentioned being referred for routine orthopedic testing by his physician, but has not received an appointment date yet.
Objective: Performed posture and ROM assessment. Provided full-body Swedish massage to address tension and gave client information on correct ergonomic lifting technique. All treatment tolerated by client who reported no pain during massage.
Assessment: Client reported 1/10 pain level following massage. No adverse reactions noted. Client understands and can demonstrate proper lifting technique.
Plan: Continue DT treatment and lower back massage. Follow up with client about pain level and posture and reassess at next visit.
Do not miss our post Massage Therapist Duties.
Massage SOAP Note Templates
We know that when you’re just starting to take SOAP notes for massage therapy, free templates can make a big difference.
That’s why we’ve put together some premade, printable massage therapy SOAP notes forms to help you get started.
Feel free to change or add to any massage therapy SOAP notes template in order to suit your practice’s needs, and make sure to let us know if we’ve missed anything.
Although it may seem like a lot of work at first glance, taking these notes doesn’t have to take up too much of your time. There are some strategies you can use to make the process easy and straightforward.
Using free massage therapy SOAP notes forms can be a big timesaver, especially when you’re first getting used to the process and want more time to focus on treatment. You can also invest in massage therapy software to optimize your whole business.
Massage therapy SOAP notes are important, and doing them correctly should make everything easier.
Learning to write case notes using the SOAP format
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