Running a successful massage therapy practice requires more than just dynamite technique. Organization and efficiency are essential to scheduling smoothly, marketing with impact and growing your business. Central to this organization is your clients’ paperwork. Not only do these documents direct your treatment plan and track progress, they can inform decisions made by insurance companies and other healthcare providers. This is why massage therapists rely on SOAP notes.
What are SOAP notes?
The SOAP note is an acronym referring to the widely-used method for documentation by massage therapists: Subjective, Objective, Assessment, and Plan (SOAP).
Subjective describes your impression of the client’s condition, including the facts presented by your client. This can include past medical history or injuries as well as personal contributing factors to pain: job requirements, lifestyle, etc.
Be sure to note how they’re feeling now and how that has changed, especially if your treatment plan has been implemented for awhile.
Subjective example: Client indicates pain in right shoulder that persists when standing and sitting and at-home ice therapy had no effect. Client rates pain level as 4/10.
To make it simple it means, “The data the therapist takes from palpation.” It also means: visual-postural analysis, limps, muscle guarding, holding patterns, inconsistencies in movements, atrophy, hypertrophy, bruises, abrasions, scars, swelling, redness, skin irregularities, varicose veins, breathing patterns and prosthetics.
Treatment goals can be added to define the intention of your massage choices and that they ensure that your treatment-plan has a purpose.
Objective example: Tissue heat and muscle fibrosis throughout right shoulder.
Assessment requires you to detail how the client is progressing through your therapy plan. You can detail or list techniques you used, what areas on which you focused and even conduct a series of short physical tests in order to assess range of motion, posture and gait.
Assessment example: Conducted range of motion tests, significantly improved after treatment. Patient reported 0/10 pain after treatment.
The plan is the treatment you intend to implement, including long-term treatment plans and lifestyle recommendations. It contains all the required steps, and details every proposed treatment, including therapies, and surgeries. For the most recent visit, you should also include what worked and didn’t work this week, what to focus on next time or anything that was missed. You can also include new short-term or long-term goals and recommendations for the client.
Plan example: Next week, focus on neck and shoulders and review stretches and self-massage techniques after a long day of standing.
When in doubt, document it.
Why do massage therapists use SOAP notes?
Like other healthcare professionals, massage therapists use SOAP notes to detail: the treatment plan, the client’s progress, new and substantial issues or pain, and notes for future treatment. They are also essential to making sure the therapist is updated before a client’s visit and has a clear vision of the goals.
Why are SOAP notes important?
Although SOAP notes are not required for massage therapists by law, many larger companies and practices do require them. As you can imagine, they are extremely important for measuring a client’s progress and giving massage therapists a refresher prior to the client’s next visit.
The most beneficial thing about SOAP notes is that they provide a benchmark, allow you to build a historical overview of your client’s treatment, and track progress efficiently. Their outline (S,O,A,P) also ensures consistency for you and other providers. Knowing what to write and how to write it also saves precious brain energy.
If you’re simply jotting down visit notes when you see clients now, imagine the consistency that can be gained from a more formal approach. As you grow your practice, your shorthand could change, your observations could become more astute, and your plans could mature.
Having a structured outline for these visits ensures that you are looking for the right progress indicators, asking the right questions and planning ahead for the benefit of your clientele.
SOAP notes are also incredibly useful when communicating with insurance companies where the more objective data that you can provide, the better.
Download your free massage therapy SOAP note template and get started on improving your practice and standard of care.
Better organization with digital SOAP notes
Even if you love writing notes on paper, this can grow extremely tiresome after a long day of client care. Furthermore, the organization of paper becomes a space-waster (think: large filing cabinets throughout your office).
Digital SOAP notes allow you to take comprehensive notes on a phone, iPad or computer, making work more flexible and mobile. They self-organize for easier recall. And perhaps most importantly, MassageBook SOAP notes allow you to set reminders so that you never forget to update again.
Avoid these common SOAP note mistakes:
❌ Making judgmental statements
❌ Documenting irrelevant personal information
❌ Diagnosing based on observation alone
Quick tips for better SOAP notes:
✅ Keep it consistent
Do what you write and write what you do. This will enable you to not only recall treatments easily, but discuss details with other therapists when needed and with insurance companies. It will also decrease your liability risk.
✅ Include all relevant details
You don’t have to rewrite your treatment plan and overall goals each week, but be sure not to skip the areas you worked on, techniques you used and any new information your client provided.
✅ Diagnose with palpation, observation & assessment
There are indicators that seasoned therapists can observe, but it’s important not to make diagnoses based on vision alone. Be sure that your SOAP notes are indicative of your treatment and palpation.
✅ Keep it professional
It’s best to keep SOAP notes descriptive of action and treatment. For example, “the client looked great” is informal and vague. Try instead, “the client said his back pain had diminished with treatment and felt much better.”
✅ Go Premium
When you’re ready to make your SOAP notes work better for you, try MassageBook’s Premium SOAP notes offering.
MassageBook’s Basic vs. Premium SOAP Notes
Both versions of MassageBook’s SOAP notes are easy-to-use, allow you to save time and space, and are HIPAA-compliant. So what’s the difference?
Basic SOAP Notes let you manually type your findings into each provided field: Subjective, Objective, Assessment, and Plan. This capability is included with all subscription plans.
Premium SOAP Notes expand on Basic by giving you the ability to add notes to the body chart using the auto-create and draw tools. These capabilities are only included with Simplify or Amplify pricing plans.
Basic SOAP note features:
- Reminders to create & update SOAP notes
- Mr. Meanie (anatomical model) opens up
Premium SOAP note features:
- Notes that write themselves
- Visual markers with draw tool
How do MassageBook Premium SOAP notes “write themselves”?
This optimum time-saver is also invaluable for keeping your notes consistent. In order to automatically structure the notes, you simply click on a part of the anatomy and select choices from a short form. Your choice is populated into the Subjective or Objective section. This is especially helpful if you share notes with other health care providers as a part of a broader treatment plan, or with insurance companies.
Visual markers allow you to easily see and remember a patient’s condition during the next visit. All client SOAP notes seamlessly integrate with individual records and your schedule for easier accessibility.
Note: For HIPAA purposes, a SOAP note that has been saved or saved as a draft cannot be deleted. The note can only be edited to include a new version.
If you’re not ready to digitize just yet, or you’re looking for the best basic SOAP note first, download the free massage therapy SOAP note template for free now!
- Author: Amber Ludeman
- Published: June 12, 2020