Wondering how to write better massage SOAP notes?
Perhaps you think your current notes aren’t quite where they should be. Maybe you came across this blog post randomly and are wondering what this better way is.
As more and more practices move to practice management software, such as medspa software, or mental health software free, (with integrated SOAP notes and intake forms), more therapists are moving away from paper massage therapy SOAP notes and toward electronic charting. There are many reasons for this, but some common reasons are that they can be stored online and they allow therapists to become more eco-friendly.
What many therapists don’t always know, though, is that electronic charting is also much less time-consuming (no filing or scanning) and more secure.
Whether you’re a brand new massage therapist or a seasoned one, this blog post will take you through how you can improve your SOAP notes so they’re not only better but also easier and faster to write!
Table of Contents
What is a SOAP Note in Massage? What Does SOAP Stand for in Massage?
Some of you might be wondering what a SOAP note even is.
SOAP notes are the formal documentation of your session. These are not to be confused with consent forms!
“SOAP” is an acronym that helps massage therapists structure their notes. While not everyone follows this format, it’s typically the industry standard.
SOAP stands for the following:
S = Subjective: The client’s description of their complaint. For example, the client’s neck is sore. This section is completed before your session.
O = Objective: Your objective findings that are observable and/or measurable, both before and during the massage.
A = Assessment: How your client responded to the treatment. It’s important to note that sometimes massage therapists will also include what areas they treated and the techniques used or if heat was used. In this way, there can be some discrepancy in how SOAP notes are taught (more on this below).
P = Plan: The treatment plan for what you want to do in the future and recommendations for self-care.
Why Are Massage SOAP Notes Important?
There are several different reasons why SOAP notes are important, even if they’re not legally required in your area. That said, they are still considered “best practice.”
Here are a few reasons why:
- They Allow You to Better Help Your Clients. We wouldn’t be surprised if you said one of your favorite parts about being a massage therapist is that you get to help people. SOAP notes help you do this. The purpose of SOAP notes is to not only document what you did but also whether it was effective. Without documenting the effectiveness of what you’re doing, you have no way to measure or draw conclusions about what’s working and what’s not working. SOAP notes allow you to make better decisions. And, if you’re working with other healthcare providers, they’ll also have access to this same information so that they can also provide the best level of care.
- They Protect You. SOAP notes serve to protect you in the event of an (unlikely) but potentially compromising situation. For instance, detailed notes will indicate which specific body parts you treated and whether verbal consent was given, all of which can provide a record of what really happened.
- They Help You Remember the Details of the Last Session. Many clients will ask you to repeat a treatment they had two weeks ago; without documenting what actually took place, you may have a difficult time remembering what exactly you did.
- They Offer a Way to Show Your Clients Their Progress. By documenting your sessions, you can easily show your clients their progress. For clients who may struggle to justify the cost of massage treatments, this provides a way to communicate just how far they’ve come.
Another common question is how long you have to keep SOAP notes.
Requirements can vary based on country and state or province. It’s not uncommon to have to keep massage therapy SOAP notes for ten years or more. That’s one of the benefits of electronic SOAP notes: as your practice grows, you don’t have to worry about storage space.
How Do You Write a Massage Note? How Do You Do SOAP Notes?
This refers to your client’s description of their complaint (and the purpose of the massage). For instance, they might come into your practice and tell you that their neck and shoulders hurt. Here is some additional information that’s good to include in this section:
- Cause of pain
- Onset of pain (date)
- What other healthcare professionals the client has seen with regard to their issue (chiropractor, etc.)
- Primary area of pain
- Pain scale
- Quality of pain (sharp, dull, etc.)
- If the pain is constant or intermittent
- What activities worsen and improve the pain
- What activities the pain prevents the client from doing
This section refers to the objective findings and includes findings that are either observed, palpated or assessed through a physical examination (i.e. range of motion or orthopedic testing).
This section refers to how the client responded to the treatment. However, there is a little more than meets the eye. Indeed, many massage therapists struggle with what to write in this section besides “The client responded well to treatment.”
Instead of only focusing on the client’s response to the treatment, this section should also be about doing a reassessment and comparing it to how their pain, range of motion and so on have changed as a result.
After all, the point of massage SOAP notes is to document what you did and whether it was useful (or not).
A good tip is to ask your clients how they felt as well.
In summary, this section should include the following:
- How the client responded to the treatment (client was sensitive to the touch)
- An assessment of their progress since their last visit (i.e. changes in pain). You can also re-run tests like range of motion and note any improvements
- An assessment of their overall progress toward their goals
- Possible causes
As mentioned above, sometimes some therapists also include the areas they treated and the technique they used. However, the format supported by the American Massage Therapy Association or the AMTA includes a separate section before the Assessment section specifically designed for treatment.
Keep in mind that this section should provide enough information that other treatment providers like doctors or chiropractors will have enough information to understand exactly what you did.
Lastly, this section details your specific treatment plan for the future and recommendations for self-care (i.e. what clients should do at home, such as stretches or increase water intake or recommendations to be referred to other healthcare providers).
A Massage Therapy SOAP Note Example
Get Your Yocale Massage SOAP Note Template
Tips for Writing Good Massage Therapy SOAP Notes
1- Focus on Reassessment (and Be Specific)
There are a variety of reasons why SOAP notes are a good idea, but with respect to actually providing the best treatment possible, one of the most important things you can do is to not only focus on what you did but to measure how effective it was (both in terms of asking your clients afterward and even doing retests as necessary).
Some massage therapists make the mistake of making their own judgments about how the client responded to the treatment (i.e. they were sensitive to the touch) without asking them or without ever retesting.
So, open up a dialogue with your clients to get their feedback. And then retest as necessary. This will help you to provide a better guide for what to do in the future.
Keep in mind, too, that this section should be specific enough to be useful.
This leads us to our second tip. If massage SOAP notes are to be useful, they need to be read, which means making them more accessible.
2- Go Digital
The problem with paper SOAP notes is that oftentimes the notes are never read again! Digital SOAP notes are much more accessible, making it much more likely that they’ll actually be read before your next session.
With massage therapy practice management software, your entire client file or chart will be condensed into one single screen. Here’s what it looks like in Yocale:
3- Make Sure Abbreviations Are Consistent Across Your Team
A common tip for writing faster massage therapy SOAP notes is to use abbreviations (and this is definitely true!). However, not only is it important to be consistent in your own notes but across your organization as well.
Indeed, some practices run into problems when it comes to abbreviations as they find abbreviations can be inconsistent across therapists.
4- Be Open to New Approaches & Test Your Assumptions
We know for a fact that you dedicate a lot of time to reading about the latest developments in massage therapy and how you can help your clients better.
But have you spent time reading about new developments that can make your life as a therapist better?
We completely understand that if you’re used to doing something a certain way (i.e paper massage SOAP notes), it can be difficult to do things differently – even if you’re drowning in paper!
But, it can be worth considering alternate perspectives and, with respect to electronic charting, why there has been a shift away from paper. In short, electronic charting is easier, more eco-friendly and safer. It also takes up much less space.
We have also seen some massage therapists say that they feel paper charts are safer. But a compliant practice management software is not open to nearly as many security holes as paper (think: ink that fades over time, legibility, fire and so on).
Electronic charting also doesn’t mean that you can’t draw or write notes by hand! With some massage therapy practice management options (like Yocale!), you can select muscle groups with a mouse either by pinning the muscle group or by drawing.
You can even handwrite your notes with a stylus on a tablet. The benefit here is that you don’t have to do any filing or scanning.
How to Write Easier and Faster SOAP Notes
1- “Visual Charting” – From Your Computer or On a Tablet
A good way to write faster SOAP notes is by replacing at least some text with diagrams where you can simply circle muscle groups instead of having to write. However, like we mentioned above, it’s commonly thought that you can only do this with paper!
Some practice management software options out there allow you to simply point and click from your computer or even on a tablet. With Yocale, for instance, you can simply pin the muscle groups or draw with your mouse.
Again, this means there is no filing or scanning involved, either. Plus, you get all of the benefits of electronic charting, too.
Create Custom SOAP Notes
2- Have a List of Frequently Used Text (or Use Software)
Another way to reduce SOAP note time is by having a list of commonly used text (such as a list of common treatment plans or self-care recommendations. That way, you can simply copy and paste.
Yocale users can even save commonly used text and simply click to add it into the SOAP note.
3- Allow Clients to Complete the Subjective Portion (in Advance of Their Appointment)
One of the major benefits of electronic charting is that there are many additional features designed to make SOAP note writing easier and faster.
One example is allowing clients to complete the subjective portion of the note themselves.
This is actually a great Yocale feature. With this, you can sync SOAP notes to the online booking process; clients will be required to complete the subjective portion in advance of their appointment, and the note will automatically get saved to their file.
(You can hide the rest of the SOAP note, too, so that the client can only see the subjective portion at any given time).
4- Dictate Your Notes
Not everyone enjoys writing. A good alternative is to dictate your notes instead (at least the portions that you can realistically dictate). This is also something you can do on Yocale.
Wrapping it Up
When it comes to writing better massage therapy SOAP notes, the best advice we can give is to really remember the heart of the SOAP note and its purpose: to document what’s working and what’s not. This will provide a clear path forward, enabling you to provide the best treatment possible.
And on the topic of writing better SOAP notes, it’s important to think about the ways that old practices (paper SOAP notes) could be slowing you down. You may be perfectly happy with your paper notes, but there are also a lot of benefits that come from electronic charting: greater accessibility, the elimination of filing and scanning, improved legibility, less storage space and greater security to name a few.
What has worked for you when writing massage SOAP notes? We’d love to hear from you!
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Interested in learning more about massage therapy practice management software? Book a demo with a Yocale product specialist today.