Documenting your massage therapy sessions with your clients is one of the essential responsibilities of being a massage therapist. Not only do these notes allow to communicate key information about a client’s ongoing treatment, but they also allow you to document their health and provide a clear roadmap to the progress that your massage therapy methods are providing.
One of the most essential types of record-keeping for massage therapy is SOAP notes. SOAP is an acronym for Subjective, Objective, Assessment, and Plan, and it is important to record the notes in this order to best create a comprehensive plan of treatment going forward. Using a massage therapy SOAP notes example template can help you to better fine your SOAP notes so that they can be used for things like medical billing or even potential legal claims or dispute of services. SOAP notes are used across many different medical disciplines, although they are of particular importance when it comes to massage therapy.
To start off your SOAP notes, you should use the client’s own testimony to document their chief compliant. This includes a full history of their medical issues that have brought them to massage therapy in the first place, as well as how severe they feel that their pain is. The type of pain, whether it is neurological, musculoskeletal, or otherwise, should also be documented in this process, and should be based off the client’s testimony.
Next, you’ll want do a small physical examination that does not use the client’s testimony. This can include checking and observing the client’s posture and checking their range of motion in various areas. This can help to better hone the massage techniques you hope to use and you can use this documentation to direct their treatment.
After you have made these subjective and objective observations, you’ll want to analyze and assess what you believe the problem is by logging all symptoms, possible and likely causes, as well as their progress from previous visits. This may help you come up with some new ideas or assess the efficacy of your massage therapy treatment on the patient.
Finally, you’ll want to come up with a comprehensive plan of action for your massage therapy client. This can include creating a treatment roadmap and assessing what their pain levels are from session to session, as well as any educational recommendations that you want to make for the client. This can include recommendations on how a client can fix their posture and also stretching techniques and exercises a client can use to help the patient relax in between massage therapy sessions. This is not only helpful for a massage therapist, but it also helpful for a client who may need to put in some manual work outside of massage therapy sessions in order to see the best results.
While SOAP notes are not always required in massage therapy, they are recommended in most instances, particularly in clinical settings where patients are intending to use medical insurance to supplement the cost of massage therapy services. It is also important to have documentation in case a client tries to bring about legal action against you, or just so that you can coordinate their care or document what treatment options have been done for future use.
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