Writing SOAP notes is not an easy task. However, it is very helpful for massage therapists to write SOAP notes in order to give the best care possible to their clients. Using SOAP notes, massage therapists can better map out a treatment plan for their clients and set clear and objective goals for their massage therapy treatments going forward.
SOAP notes use a particular format, and they stand for Subjective, Objective, Assessment, and Plan. Each component of SOAP notes can aid you in better codifying a client’s condition, progress, and care in between sessions. Before writing your own SOAP notes, it is important to review examples of massage therapy SOAP notes so that you can best create a comprehensive plan of action for your massage therapy clients.
With that in mind, here is the key components of writing SOAP notes for your massage therapy business.
Creating subjective notes is the first thing you will need to do when creating SOAP notes. This includes the client’s description of their chief complaint, and should include the client’s narrative history of their chief complaint along with any relevant medical history and other concerns, such as nerve damage or musculoskeletal issues.
SOAP notes also have an objective component which requires a massage therapy to use data that is either found via massage therapy or by other medical professionals. This includes things like blood pressure tests, testing vital signs, and even physical examinations. This can include observations such as a client’s poor posture including their range of motion. This component isn’t meant to draw any particular analysis. Rather it is meant to show what areas a client is struggling with in relation to massage therapy.
Assessing a client’s condition and progress with massage therapy is a key part of the responsibilities of a massage therapist. This section should include a summary of a client’s symptoms, an assessment of how different treatment options within massage therapy can help these symptoms, and ultimately how both the client and therapist feel about the progress of their treatment.
The plan is the most comprehensive element of SOAP notes in massage therapy. The plan allows a massage therapist to create treatment options for follow-up visits and overall treatment goals. They can also help to convey educational procedures and information that client should take heed of in between visits, and also pass on any treatment plan information to other medical professionals who are working with a massage therapist, such as a referring physician.
Overall, SOAP notes serve as a treatment framework for massage therapists. They can help them better select treatment options, analyze the efficacy of their massage therapy techniques, and utilize both patient feedback and their own observations in treatment. SOAP notes also serve as a legal framework in case a client decides to sue for malpractice or believes they are not getting the treatment they signed up for. By documenting all of your interactions and massage therapy sessions with clients, you will have a much better sense of how your sessions are going and where you can have the most impact with your massage therapy in follow-up sessions.