SOAP Notes Massage Tips
As a licensed or certified massage therapist, it’s essential to know about SOAP notes and how to properly and effectively record them as part of your sessions. SOAP notes will help you determine what you need to work on with your client as you go through the session. That way, you can make the time spent with them as effective as possible. It will also allow you to help establish a treatment plan for your client that can be used by other massage therapists going forward. This is everything you should know about recording useful SOAP notes as part of your sessions.
Related: The Power of Touch
What are Massage Therapy SOAP Notes?
Health care professionals like massage therapists typically use SOAP notes to document and keep track of clients' health records. SOAP is a special acronym that stands for the words subjective, objective, assessment, and plan. Over time, this type of note has become the standard for massage therapists to use in their practice, and they are critical for several reasons. They provide massage therapists a way to maintain a structured approach to their sessions and keep track of specific client information. This structure allows them to create outlines of their appointments to use the limited session time as effectively as possible to help their clients.
This section is where massage therapists document their clients’ complaints, like significant pain locations and their frequency or intensity. This section is considered to be “subjective” because its contents are up for interpretation. While one client may describe something incredibly painful to them, another client may only refer to the sensation as uncomfortable.
This section contains the information that a massage therapist gathers through visual assessment and testing done through massage. The information in this section is considered objective because any qualified massage therapist should be able to reach the same or similar conclusions in their examination of the client.
The assessment section contains the outcomes and functions of the session. This section is also where a massage therapist can document any limitations that the client is experiencing. Such limitations could include things like a reduced range of motion or a hindrance in their flexibility. After that information is recorded, massage therapists can include their educated reasoning behind both the subjective and objective sections of the SOAP notes.
This is the final and arguably the most straightforward section of the SOAP notes. It’s where massage therapists record the course of treatment for the session and any recommended treatment options for the future.
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Are Soap Notes Required for Massage Therapy?
There are times when SOAP notes are necessary and other times when they’re not. For example, a five-minute chair massage at a company’s charity event would not require any SOAP note documentation. However, therapists are unlikely to encounter a large amount of such short sessions in their regular work. The type of SOAP notes that a massage therapist takes primarily depends on their company’s standards, regulations, and general rules regarding note-taking. Therapists need to be sure that they are meeting their employer’s standards and expectations regarding their notes, though not all companies will have the same requirements. A general rule of thumb is to record SOAP notes for longer sessions and when working with clients that you are likely to see again.
SOAP Note Message Tips
Now that you fully understand what SOAP notes are and why they are essential in massage therapy, here are some of the top three tips on creating useful notes. These will be of use to yourself and your client, as well as other massage therapists who end up working with your client in the future. Keep these tips in mind as you begin taking your SOAP notes to ensure that they are as thorough and useful as possible.
Use neat writing
It’s crucial to ensure that your handwriting is legible not only to yourself but to other massage therapists who may end up working with your client in the future. Using clear, neat writing will allow other therapists to pick up right where you left off with the client.
Get to the point
Massage therapists often have little time between their sessions, so SOAP notes need to be written up quickly and efficiently. Be sure to keep your notes brief and include only pertinent information so that other therapists will get through them without issue. Try to keep your sentences short, direct, and avoid using any unnecessary words.
Use common abbreviations
The abbreviations used may differ slightly between workplaces, but massage therapists have a general, fixed set of standard and easily recognizable abbreviations developed by trained industry professionals. Make sure to stick to these abbreviations to avoid confusing other therapists who have to work off your notes.
Are SOAP notes required in a Yomassage session?
Yomassage always includes SOAP notes in their signature, table, and barefoot sessions, even if they are very basic or brief. However, these notes aren’t typically used during their Self-Care or Mindful Touch sessions. Yomassage covers how to create practical SOAP notes as part of the basic training courses for massage therapists, and they also have SOAP note sheets available via their membership portal. Therapists can access, download, and use these note sheets at any time.
SOAP Notes: Final Thoughts
As discussed at the beginning of this article, SOAP notes are an essential element of massage therapy that all certified and licensed massage therapists need to know how to create effectively. While the requirements regarding these notes' content vary from company to company, therapists must understand what their employer expects them to record and why. These notes serve as a foundational component of clients' treatment plans and must be created with care. Please make sure that you fully know and understand your employer's requirements regarding these notes and how to create them.
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