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SOAP Notes for Massage
(Subjective Objective Assessment Plan)
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. 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.
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.
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.
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? Insurance Billing - complete information on how to bill insurance companies for massage therapy services with links to forms, sample chart notes, and more.
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