SOAP Notes for Massage
(Subjective Objective Assessment Plan)
for Bodyworkers/Massage Therapists
The purpose of SOAP charting is to record the
client's condition and progress that occurs in each session of bodywork/massage.
It is usually required for sessions that will be paid for by an insurance
company, whether it is a PIP (auto mobile), L&I (Labor and Industries) or Major
Medical. Your records may be requested by physicians to keep them updated
as to the condition of the client or by lawyers who need them as records of the
clients injury and progress. Either way, it is important to keep the
clients charts updated and complete. This is just a simple overview of SOAP
charting. In order to bill insurance companies you will need to be
proficient in charting and also writing reports to insurance companies and
doctors. The best book on charting is called
Hands Heal: Communication, Documentation, and Insurance Billing for Manual
Therapists (LWW Massage Therapy and Bodywork Educational Series)
Subjective: The client's subjective complaints and symptoms that are in
the clients own words or may have been discussed by the prescribing
physician. This includes all the things the client tells you about how
they are feeling, past history, present symptoms, limitations in their lives
due to the injury, what makes them feel better or worse, and details about
the initial onset of the problem or injury. It is often helpful to ask
the client to rate their pain or discomfort on a level 1-10 with 10 being
the worst. If you do this each time, you will be able to see
improvements or setbacks.
Ask specific questions as to the location, intensity, duration and frequency
of the pain or discomfort. Have the client point to the specific area on
their body or body chart. Ask how painful is it? How long have
they had it? Hours? Weeks? Months? Longer? Has it been worse or better? What
makes it worse or better? How often do they get it? Every day? Once a week?
Asking specific questions will lead to a clearer picture of the
problem/injury you are treating.
Objective: This is the observations of the
practitioner and what techniques were done during the session. This includes
visual observations and what you feel in the body of the client. Include things
you observe about the clients posture, patterns, movement, weakness, level of
tension in the tissues, spasms in muscles, joint movement, color/temperature of
skin and breathing patterns.
You can also test the range of motion in different areas and keep track of
their improvement or changing patterns.
Some common findings are defined below:
Hypertonicity: involuntarily tight or contracted muscle; excess
muscle tone; the tension of the resting muscle is unusually high.
Spasm: involuntary contraction of a muscle as a protective response
to an injury or trauma.
Trigger point: specific point that refers pain
Adhesion/scar tissue: the resulting tissue from the wound healing
process causing a restriction in resiliency of the tissue
Assessment: As most bodyworkers or massage
therapists are not allowed to diagnose conditions, this is to report the
immediate results of the session. At the end of the session reanalyze the
posture and range of motion. Make notes on any changes in symptoms.
Indicate how much change happened- mild, moderate or significant change. Use as
many descriptive words as possible.
Most insurance companies will take this information into consideration when
paying for the treatment. This is what is telling them if the client is
getting better and is the treatment worth it.
Plan: Suggest a treatment frequency and things that
need to be addressed in the future. Include any self care instructions you
gave to the client, special requests by the client, or reminders for the next
session.
See also:
What should SOAP notes say?
Functional outcomes reporting
Massage Insurance Billing Manual
- complete information on how to bill insurance companies for massage
therapy services. Learn what codes to use, how to build a doctor referral
network, how to get paid the most in the least amount of time- Vivian
Madison- Mahoney's comprehensive guide to insurance billing. (CE
credits available)
