Massage SOAP Notes - Introduction

Student Support

What should I write in my massage SOAP notes?

We keep seeing different versions of this question posted regularly in various forums over the web. So, we decided to do our part and address it here.

Acknowledgment

Before we start, we need to give credit where credit is due: Diana L. Thompson wrote "Hands Heal: Communication, Documentation and Insurance Billing for Manual Therapists" which has a great chapter dedicated to SOAP charting. This is The Book you need if you want to learn everything there is to know about Massage SOAP Notes, and much more.

The answer

The answer is quite long, so we divided it into sections that you can easily access using the buttons at the left of this text.

Here is the outline:

Therapist Information
Client Information
Session Information
Subjective
- Client Focus
- Contraindications and health concerns
- Current Medications
- Symptoms
- Activities of Daily Living
Objective
- Visual Information
- Testing
  - Range of Motion Testing
  - Muscle Strength Testing
- Palpation
  - Body drawing
  - Muscle symptoms
- Modalities
Assessment
- Functional Goals
  - Short Term
  - Long Term
- Functional Outcome
Plan
- Treatment Plan or Discharge Notes
- Homework

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Next: Therapist information.

Questions? Email support@wincityinc.com