Student Support

Objective - Palpation

In this part of the SOAP Notes , you record the location, the severity before the treatment and the severity after the treatment of various symptoms you observed through palpation.

Location

To indicate the location, you can record your observations directly on a picture of a human body, or you can simply list the muscles, groups of muscles or body regions that are involved.

If you indicate something in the muscle list, it is not necessary to represent it on the picture of a human body.  If you indicate something on the picture of a human body, it is not necessary to represent it in the muscle list. 

Symptoms

Typically, you would list symptoms such as:

•  adhesion

•  hypertension

•  inflammation

•  numbness

•  scar tissue

•  spasm

•  tender points

•  trigger points

Avoid listing every minor symptom. Only list the most significantly ones.

Focusing exclusively on hypertension is a common mistake. Make sure you record inflammation, spasms, adhesion, numbness, etc. as well. 

Severity

Use the severity scale of your choice to qualify the symptoms' severity.  WinCity Massage SOAP Notes uses the LMS severity scale. This scales has three main levels of severity: low (L), moderate (M) and severe (S). One good way to use this scale is to use the low (L) level to describe symptoms that do not limit your client's activities, the moderate (M) level to describe symptoms that force your client to modify or limit an activity, and the severe (S) level to describe symptoms that force your client to stop some activity. Each level itself can be modified with a minus (-) or plus (+) sign to further differentiate the severity levels. We thus have a 9 level scale: L-, L, L+, M-, M, M+, S-, S, S+.

Putting it all together

The following example states that we observed tender point, pain, hypertension and spasm in our patient's neck and pain in her upper trunk. In all cases the symptoms where observed on both sides of the body (BL) with en emphasis on the right side (+R). These symptoms's severity were rated S- before the massage session, and M+ after the session.

The next example shows a graphical representation of symptoms:

Next: Modalities

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Last modified: 06/10/08