SOAP Note Template for Massage Therapists [Free Download]
- Amber Ludeman
- September 22, 2022
- - Resources
Updated September 22nd, 2022
Save time and record detail-rich SOAP notes with this free massage therapy SOAP note form
Now you can go paperless with a digital SOAP note form you can type into and draw on. Make as many copies for as many clients as you need, and start making the most of your time each day. Pretty soon, you’ll be creating better client notes and, ultimately, a better client experience. Plus, your free download includes a printer-friendly version of the form if you’re still using paper records.
Running a successful massage therapy practice requires more than just great technique. Organization and efficiency are essential to scheduling smoothly, marketing effectively, and growing your business. Central to this organization are the SOAP notes you record for your clients. These documents help you create treatment plans and track progress and are beneficial when working with insurance companies and other healthcare providers. This is why massage therapists rely on SOAP notes.
What are SOAP notes?
SOAP is an acronym for the method of documentation used by massage therapists to record notes about clients: Subjective, Objective, Assessment, and Plan.
S = Subjective
Subjective describes your impression of the client’s condition, including the facts presented by your client. This can include past medical history or injuries and personal contributing factors to pain such as job requirements and lifestyle. Be sure to note how they’re feeling now and how that has changed, especially if your treatment plan has been implemented for a while.
Subjective example: Client indicates pain in right shoulder that persists when standing and sitting, and at-home ice therapy has had no effect. Client rates pain level as 4/10.
O = Objective
Simply put, it means the data the therapist takes from examination by touch. 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 the massage techniques you’re using and to ensure that your treatment plan has a purpose.
Objective example: Tissue heat and muscle fibrosis throughout right shoulder.
A = Assessment
Assessment requires you to detail how the client is progressing through your therapy plan. For example, you can detail or list techniques you used and what areas you focused on. You can even conduct a series of short physical tests to assess the range of motion, posture, and gait.
Assessment example: Conducted range of motion tests, significantly improved after treatment. Client reported 0/10 pain after treatment.
P = Plan
The plan is the treatment you intend to implement, including long-term treatment plans and lifestyle recommendations. It contains all the required steps and lists every proposed treatment, including therapies and surgeries. For the most recent visit, you should also include what worked and didn’t work this time, what to focus on next time, and anything 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.
Why do massage therapists use SOAP notes?
Like other healthcare professionals, massage therapists use SOAP notes to detail the client’s treatment plan, progress, new and substantial issues or pain, and notes for future treatment. They are also essential to ensuring 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 require them. As you can imagine, they are essential 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 could 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.
Lastly, SOAP notes are also incredibly useful when communicating with insurance companies. The more objective data you can provide, the better.
Quick tips to help you record better SOAP notes
❌ Avoid making judgmental statements
❌ Avoid documenting irrelevant personal information
❌ Avoid diagnosing based on observation alone
✅ Keep it consistent. Do what you write and write what you do. This will enable you to recall treatments easily and 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. However, don’t skip the areas you worked on, techniques you used, and any new information your client provided.
✅ Diagnose with palpation, observation, and 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.”
Download your free massage therapy SOAP note template to save time and improve your standard of care. A digital and printer-friendly paper version of the form is included to meet the needs of your practice.
Simplify your day with digital SOAP notes
Even if you love writing notes on paper, it can grow tedious after a long day of client care. But that’s not all. Organizing paper eventually becomes a space-waster (think: large filing cabinets throughout your office).
Digital SOAP notes allow you to take comprehensive notes on a phone, tablet, or computer, making work more flexible and mobile. Plus, they’re easy to store, organize, and locate. And if you’re a visual person, you’ll love how simple it is to draw notes on the anatomy chart in an endless array of colors.
Enjoy faster, more detailed, and more useful digital SOAP notes from MassageBook
MassageBook’s easy-to-use practice management software:
- Streamlines your note-taking
- Reminds you when to create new notes
- Keeps your client records organized to a tee
- Puts vital client information at your fingertips
- And comes complete with a customizable client intake form
Even better, you can breathe a sigh of relief knowing that your SOAP notes are HIPAA compliant, feature top-of-the-line data security, and maintain a complete archive of any changes made over time.
If you’d like to save more time, record professional-quality SOAP notes, and get rid of your paper filing cabinet, now’s a perfect time to explore how MassageBook’s SOAP notes feature can help you reach new levels of productivity.
Try the premium version free for 30 days. After that, you can even keep using the basic version free for the rest of your first year on MassagBook!
Create your free account now to simplify your SOAP notes
Not quite ready to join MassageBook? With our free massage therapy SOAP note template, you can still experience the benefits of digital SOAP notes today!
- Author: Amber Ludeman
- Published: September 22, 2022
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