How to Write an Effective Massage Therapy SOAP Note: What to Include and What to Avoid

SOAP notes are a foundational part of professional massage therapy practice. They help track client progress, maintain clear communication, and protect both you and your clients in the case of misunderstandings or legal issues.

Whether you’re documenting for clinical accuracy, insurance reimbursement, or your own records, knowing what belongs in a SOAP note—and just as importantly, what doesn’t—can make all the difference.

What Is a SOAP Note?

The SOAP format is a widely used documentation method in healthcare. It stands for:

• Subjective
• Objective
• Assessment
• Plan

Each section plays a key role in capturing a complete picture of your session and the client’s condition. Here’s how to write each part properly—and what you should avoid along the way.

Subjective: What the Client Reports

This section includes everything the client tells you about how they’re feeling. That could be:

• Their chief complaint (e.g., “My neck feels tight after work”)
• Description of pain or discomfort
• History of the issue (onset, duration, triggers)
• How they responded to previous treatments
• Any updates on medications or health conditions
• Their personal goals for the session

It’s helpful to use pain scales (like 0–10) and ask follow-up questions to clarify their symptoms. For example, if a client reports experiencing shoulder pain, ask when it began, what movements exacerbate it, and how long it persists.

What to avoid:

• Adding your personal opinion here
• Judging or dismissing their report (e.g., “client exaggerates”)
• Including unrelated personal chit-chat

Keep it client-centered and relevant to their treatment.

Objective: What You Observe

This part is all about your professional observations and measurable data from the session. Examples include:

• Postural assessment
• Palpation findings (e.g., tension in trapezius)
• Range of motion
• Skin temperature or color changes
• Any orthopedic or movement tests performed
• The client’s physical responses during the massage
• Techniques you used and areas treated

Be specific with what you did. For example:

“Applied myofascial release to the right rhomboids for 5 minutes with the client prone.”

What to avoid:

• Making a medical diagnosis (e.g., “rotator cuff tear” without a physician’s confirmation)
• Vague language like “massaged back”
• Non-measurable statements like “client seems better” without supporting data

Stick to observable facts and treatment details.

Assessment: Your Clinical Impressions

The assessment section is where you give your professional interpretation of how the client responded to the session and how they’re progressing.

Here’s what to include:

• Your impression of the client’s condition or improvements
• How today’s session compares to previous ones
• Any adverse responses
• Noted patterns in symptoms
• Updates to clinical goals

For example:

“Client reported a 3-point decrease in pain following trigger point therapy. Range of motion improved slightly in cervical rotation.”

What to avoid:

• Diagnosing or speculating outside your scope
• Generic comments like “treatment went well” without detail
• Emotionally loaded language

Keep it factual, focused, and within your professional scope.

Plan: What’s Next

This final section outlines what comes next for the client’s care.

Include:

• Recommended treatment frequency
• Future focus areas or goals
• Home care instructions (e.g., stretching, hydration, rest)
• Any referrals to other healthcare providers
• Notes for reassessment

Example:

“Client to return in one week for focus on lower back. Reassess hamstring flexibility next session. Recommended daily hamstring stretches.”

What to avoid:

• Vague plans like “keep doing what we’re doing”
• Unexplained changes to treatment
• Skipping home care instructions when they’re relevant

The plan should give clear direction and continuity of care.

Important Extras to Include

Regardless of the SOAP format, every note should include:

• Client name
• Date of session
• Time of session
• Your full name and title
• Signature (if required in your practice)

These details are essential for maintaining legal, professional records and ensuring clarity if notes are reviewed later.

What Shouldn’t Be in a SOAP Note

Now that you know what to include, here’s a quick list of things you should leave out:

• Irrelevant personal information (“Client talked about their weekend trip”)
• Non-standard abbreviations (“Fx” could mean friction or fracture—be clear!)
• Emotional language (“Client was annoying” or “seemed lazy”)
• Guesswork or diagnoses outside your scope
• Overly casual phrasing (“Just did a relaxing massage”)

Remember: SOAP notes are professional legal documents. They could be reviewed by insurance companies, physicians, or even in court. Keeping them clear, objective, and clinical is key.

Final Thoughts

Massage SOAP notes don’t have to be lengthy, but they do need to be thorough. They’re your tool for tracking progress, improving client outcomes, and maintaining professional standards.

By including only relevant, factual information—and avoiding judgment, vague language, or assumptions—you’ll create clear, effective documentation that serves you and your clients well.

Whether you’re just getting started or looking to tighten up your note-taking habits, a good SOAP note can make a big difference.

 

Related:

1. Free SOAP Notes Form
   (Downloadable template for documenting massage sessions) American Massage Therapy Association

2. AMTA Forms & Templates
   (Includes SOAP notes, intake forms, and healthcare provider letters) American Massage Therapy Association+1

3. Standards of Practice in Development
   (Upcoming national guidelines to shape documentation expectations) American Massage Therapy Association