One of the massage therapists’ daily routines is writing treatment notes. The standard form that they use to record clients’ information is called the SOAP note.
A SOAP note is a documentation format used by health workers and massage therapists to record their client’s treatment.
SOAP is an acronym whose full meaning is subjective, objective, assessment and plan. The SOAP provides an organized structure that enables the therapist to document the essential things on the client’s encounter.
The subjective part contains the complaint, symptoms and all the information that the client tells you about their problem in their words.
Objectives are the clinical findings and the observation by the therapist.
Assessment is the therapist’s assessment of the patient’s response to the treatment and their progress toward goals.
The plan section includes details of the next visit and instructions to the patient.
There are so many variations of the SOAP document and differences in the information that goes into every section.
Are SOAP notes needed in massage therapy?
This will mostly depend on the setting of the massage. If you’re in a clinical setting, this will be vital to tell the progress and assess the ongoing massage treatment.
Why documenting is essential for massage therapists:
Helps in tracking the progress
With SOAP notes, the therapist creates a treatment record and therefore, can track the client’s progress toward the set therapy goals.
Communicating with other therapists
If for instance, you’re working in a multi-therapist clinic, and another specialist wants to see the client, SOAP will help them understand the progress, and also leave a record of what treatment and technique used for the client.
For future reference
Proper documentation makes it easy to remember the previous visit and the therapy details of the session. Again, it reminds you of your intention for a visit. Time will pass before you see the client again, and if you have documented the progress, it’ll be easy to recollect a few details to help you prescribe appropriate therapy.
When you document the massage interventions, it will help you mitigate risks in case the client accuses you of negligence, wrong prescription or causing an injury. When everything is documented, it becomes easy to get yourself out of the woods. Many insurance companies require SOAP notes as well for coverage.
Helps in noting special needs
Massage SOAP notes help you to remember details about every client. For instance, when you have documentation, you know which one has an allergy to some oils, skin sensitivity, or injuries.