SOAP notes are a task-oriented approach to documentation and were originally designed to be used by medical doctors. Over time, SOAP notes were adopted by other allied health care providers. SOAP stands for:
Subjective information is information obtained from the client and is based on or influenced by his or her opinions, attitudes, feelings, and beliefs. Subjective information can also be obtained from the client’s family and friends. When using SOAP notes during the first client session, the subjective section contains the client’s experience of his or her condition, including symptoms and their duration, when and how the condition started, what makes it better or worse, what has been done to treat it until now, and the results of those treatments. Include any injury or history of overuse that may have precipitated the condition. In future sessions, the S, or subjective section, will state the client’s updated, current experience of his or her condition, including impressions or responses to the previous session.
Objective information is assessment-based information that can be measured and verified. If a client comes into a massage therapist’s office and enters his or her height and weight on the intake form, the information is subjective. If the therapist uses a tape measure and a scale to determine the client’s height and weight, the information is objective. Keep in mind if the client tells you of any test results, this would be regarded as subjective information. If the client gives you an official document that contains test results, the document would be regarded as objective information.
Assessment is the name of this domain in health care settings and includes the diagnosis if one has been provided by the referring health care provider. However, many massage practices use the domain name application. This section is a summary of what occurred during the massage such as techniques applied, bolstering, and adjunctive methods such as heat or cold applications.
The plan section includes treatment plan details, such as frequency of future massage sessions, the focus of these sessions, discharge notes, and any home care or referral recommendations.
A sample SOAP note is below. The sample includes body diagrams and pre- and post-massage numeric pain scales.
Salvo, Susan G. (2019). Massage Therapy: Principles and Practice (6th Edition). St. Louis, Missouri: Elsevier
Dr. Susan Salvo is a massage therapist, author, educator, researcher, explorer, and perpetual student. To learn more, check out the “About Susan” tab. You can contact Susan at email@example.com.