SOAP in massage therapy is a short form of Subjective, Objective, Assessment, and Plan. In healthcare services, SOAP is a way of documentation that health care providers use to document notes in a patient’s chart. A massage therapist’s work is to examine and treat physical dysfunction and pain problems in the joints and soft tissues of the body. Massage SOAP notes help in achieving that by documenting a client’s health history. Let’s look at the components of SOAP notes one by one.
The subjective part of massage SOAP notes refers to the client’s primary complaint. It explains the client’s reason for getting the massage. It can be back pain, joint pain, etc. Here the massage therapist records what the patient is feeling in the patient’s own words. That is why it is known as subjective since it is up for interpretation. For instance, one individual can say ‘a little sore’ while another will say ‘it hurts a little,’ but they all refer to the same thing.
Subjective documentation includes things such as:
Intensity: how severe or weak the pain is.
Frequency: how often does the pain strike-it be every evening, morning, a temporal pattern, or a permanent one.
Duration: how long the pain lasts.
Character: this refers to the pain; it can be a sharp pain, achy or shooting pain, etc.
Location: This is where the pain occurs, for example, the lower back pain.
Onset: refers to when the patient started experiencing the pain.
Aggravating factors: this refers to what increases the pain, for example, posture.
Relieving factors: what relieves the pain, for example, pain killers.
History: it is the patient’s health history record.
Alternative healthcare: other therapies or treatments the patient undergoes.
The objective component of massage SOAP notes documents the therapist assessments and what he/ she has been able to collect through tests such as massage, palpitations, and visual checks. It is known as objective because any other massage therapist can gather similar or different information.
For instance, as a massage therapist, you can note a client’s hunched posture through a visual examination. Upon a massage test, you can tell if a particular muscle was tight on the right side than the left side. So, the objective component identifies things such as:
- The patient posture when standing or sitting.
- How the patient walks-the gait.
- The patient’s pain expression on a pain scale.
- The pain area’s texture- any skin changes such as edema or swelling, any scar, or uneven surface.
- Temperature, tenderness, or tone of the pain area.
After listening to the client’s complaints, you have to assess them through massage therapy and record the function of the massage and its outcome. That makes the assessment component of massage SOAP notes. You can also add extra notes such as the limitations your client is experiencing, for example, a lack of flexibility. Here you give and record an educated assessment as a result of the subjective and objective components.
The planning part involves the massage treatment plan to help the patient overcome the subjective component’s symptoms. It refers to both the current session treatment and future treatment plans.
Massage SOAP notes play a critical role in managing long massage sessions of clients and doing follow up treatments. It may not be necessary for short-minute sessions like five-minute chair massages, but longer massage durations warrant documentation.