Massage SOAP Notes - Assessment

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Assessment

In this section of the soap notes, massage therapists record functional goals and functional outcome.

Functional Goals

Use this section to provide long and short term goals that are:

specific to a daily activity (E.g.: “walk up a flight of stairs…”)
measurable, (“… made of 10 steps, 3 times a day, every day, with no more than moderate pain …”)
attainable,
relevant to your client’s ability to earn a living and care for himself/herself and family.
time bound (“… within 30 days.”)

Example: “Eduardo will be able to walk up a flight of stairs made of 10 steps with no more than moderate pain 3 times a day every day, within 30 days.”

Short term goals should be attainable in 2 to 4 sessions.

Long term goals should be attainable in 4 to 8 sessions.

Typically, only one long term goal and one or two short term goals are needed.

Functional Outcome

Use this section to record goals that have been achieved.

Example: “As of September 25, 2004, Eduardo is now able to walk up a flight of stairs made of 10 steps with no more than moderate pain, 3 times a day every day.”

To learn more about this subject, consult Outcome-Based Massage, by Carla-Krystin Andrade and Paul Clifford.

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