As a registered massage therapist, you know you’re giving the best care possible. But when a client leaves and you move on to the next one, you risk forgetting details about the previous appointment. And those details are the key to a successful follow-up and long-term client satisfaction.

Luckily, using a strong note-taking strategy can help keep everything organized. SOAP notes – which stands for subjective, objective, assessment, and plan – give you a practical template to follow, so you can easily follow up with clients after a full day.

Here’s how SOAP notes for massage therapy can transform your practice, grow your client base, and help you earn more.

What Are SOAP Notes? 

The SOAP notes outline gives you a structured way to track clients’ progress. With this format, you capture reported symptoms, your own professional observations, and treatment strategies, from consultation to results and everything in-between. You’ll never forget a detail, ensuring clients get the best possible care.

Why Is Documentation Necessary for Massage Therapy?

Just as spa music and the smell of essential oils set a calming vibe in your space, documentation shows clients you’re invested in creating a progress-oriented treatment plan. And while SOAP notes aren’t the only note-taking method, they’re a best practice for a few reasons. They give you the tools to:

• Track client progress: SOAP notes give you a clear view of each client's treatment. They help you monitor individuals' body condition, developments, and setbacks so you can personalize each massage.  That personal touch lets clients know you’re committed to your practice and their progress.  
• Create continuity of care: Every team member needs to be on the same page regarding a client's history and treatment plan, and SOAP notes offer the documentation you need. Even if you work solo, this record maintains each client’s quality of care – whether they take a break from massage therapy or start going to someone else.
• Comply with legal and ethical standards: Accurate massage SOAP notes can protect your livelihood in a legal situation. If litigation occurs, these records help demonstrate that you've provided professional, compliant care. 
• Educate and inform clients: SOAP notes provide a foundation for client communication. They explain the “why” behind your services, helping clients understand every decision, ask questions when necessary, and trust your care. 

How To Write SOAP Notes

SOAP notes help you take the best care of your massage therapy clients. Here's how to write these notes effectively:  

Subjective

How does your client feel? Record what brings them in, any specific complaints, and relevant personal history that could impact their treatment. Document their reported pain exactly as they describe it so no symptoms or sensations get lost.

For example, if a client reports back pain, record the pain’s location and the potential cause, such as working long hours on their feet. Include relevant details like a personal history of working physical jobs, how severe the pain is, and whether or not they've been taking pain medication. 

Objective 

Document your observations before, during, and after the massage. Did their posture improve? Do they have particularly tense spots? Are there changes in skin color or muscle tone? 

Remember, this section focuses on observable facts to keep records reliable and accurate. Leave biases and personal opinions at the door.

Assessment

For all clients, analyze subjective and objective information to determine their condition. This can include a summary of symptoms, possible causes, and ideal outcomes. If a client is in for a follow-up visit, evaluate progress since their last appointment. 

For example, if a client complains of neck pain, consider the symptoms alongside their possible causes, like working at a desk and living a sedentary lifestyle. Then, ask them how they feel after treatment – physically and emotionally – to record their response to the massage.

Make clear statements about your client’s response. Instead of writing that they tolerated the massage well, which people can interpret in different ways, write that they reported less pain after treatment, which is more concrete. 

Plan 

Outline recommendations for your client's treatment plan. How will you help them, and how often should they rebook? Map out future sessions, which may include updated goals, referrals, or follow-ups. If a client’s only seeing you for one appointment, consider including a self-care plan they can follow at home.

4 Tips for Writing Practical SOAP Notes  

Follow these four tips to document your clients' journeys successfully:  

1. Write Clearly and Concisely

Use clear language in your SOAP notes to avoid misunderstandings. Straightforwardness makes for clear communication and accurate client records – both of which are essential for effective care.

2. Use Standardized Terminology 

Write with professional language to maintain consistency and make sure other health professionals can easily understand and follow treatment plans. Use recognized massage therapy terms whenever you can.

3. Write Right After the Session 

Don't wait to write your SOAP notes. Document everything while the events and thoughts are still fresh. You don’t want to forget details or record inaccuracies that can impact your client's quality of care down the line.

4. Review Your Notes 

Take an extra moment to review the notes after you write them. This helps you catch any errors or omissions so you – or your clients’ future massage therapists – have all the information you need to maintain the best standard of care. 

SOAP Notes for Massage Therapy: Example

Here’s an example of massage therapy session documentation. Feel free to use it as a SOAP notes template for your own sessions. 

Date/Time: July 8th, 2024, 3 p.m.

Client name: Alex Campbell

Therapist name: Sam Bryant

Session length: 50 minutes

Subjective: 

• Client reports persistent lower back pain.
• Describes the pain as continuous, possibly due to long hours at work.
• They said, "The pain gets worse toward the end of the workday and sometimes wakes me at night." 
• Client states they have not had a massage in several months.

Objective: 

• Client exhibits a reduced lumbar range of motion and notable lower back stiffness.
• Pain scale is 6/10.
• Palpation reveals muscular tightness and knots in the lumbar paraspinal muscles.

Assessment: 

• Examination suggests the client's pain is linked to muscle tension and poor ergonomic workplace practices.
• This may be exacerbated by a lack of regular movement and stretching.
• Client's pain scale is 3/10 after massage.
• No adverse reactions to massage.

Plan: 

• Gave client handout on workspace ergonomics and educated them on correct posture.
• Provided list of exercises for client to do at home.
• Continue targeted lumbar region massage therapy twice weekly for the next four weeks.
• Use deep tissue massage to alleviate muscle tightness and manual therapy to enhance mobility.
• At the next visit, follow up with client on daily stretches and ergonomic workstation adjustments.

Enhance Your Massage Therapy Practice With GlossGenius 

Getting your SOAP notes right helps you tailor massage sessions to clients' unique needs and offer a more transformative experience. But to really step up your game, try out an all-in-one business management app that has a client notes feature directly built in, like GlossGenius. 

Try GlossGenius free for 14 days!

GlossGenius automatically prompts you to review relevant client notes before the appointment and update them after checkout. The best part? You can get started for free. Sign up for a 14-day trial today and let GlossGenius keep the details in check while you help your clients thrive.