Yep, most massage therapists learn about SOAP notes in school. But it might be a good idea to review if you:

  • Are a student who is still getting the hang of SOAP notes
  • You work in a spa-setting that uses more informal notes
  • You’d like to work more closely with other health professionals
  • You want to be awesome. (Of course you do!)

What does SOAP mean?

Traditionally, SOAP stands for Subjective findings, Objective findings, Assessment, and Plan. Massage therapists often replace Assessment with Action (which is to say, treatment), because it makes more sense for the work we’re doing. This was how I was taught in school and how we do it at work, so that’s what you’re stuck with reading about. :)

Subjective vs. Objective: What gives?

Can you

  • See it?
  • Feel it?
  • Hear it?
  • Smell it?
  • Measure it?
  • Read it in a lab report?

Then it’s objective. (Please don’t taste your clients.) What are some examples of objective information?

  • “Client’s blood sugar was 132 prior to treatment.”
  • “Bilateral tension in trapezius and rhomboids.”
  • “Deep purple bruising on medial aspect of knee.”
  • “Client walks with a limp, favoring the left leg.”

Subjective things are what your client tells you. Examples include

  • “Client complains of recurring headaches, ~1 every two days.”
  • “Client rates pain at 4/10.”
  • “Client reports that her pain has decreased since last treatment.”
  • “Client reports having injured herself while building a bookcase on Tuesday.”

Subjective sneak-attacks

One thing that can be tricky is that your client will sometimes tell you something objective about themselves, like “The doctor said it was a sprain.” But I’m a bit picky about this one, because clients are often mistaken about exactly what they’ve been told by the people who care for them (osteopenia vs. osteoporosis, for example). So if I haven’t seen it in writing, it goes under Subjective, prefaced by “Client reports …”

This isn’t to say that you shouldn’t trust your clients. But labeling unverified information as objective fact can bite you (and your client) in the butt if somebody else tries to rely on your notes in their treatment.

Got it! What’s next?

Tomorrow I’ll cover A and P (this is beginning to sound like a Sesame Street episode) and the five most useful words I’ve ever learned.

(Okay, maybe most useful in a massage setting. “Large veggie pizza, no cheese,” has done an awful lot for my quality of life lately, but that’s neither here nor there.)

photo credit: Tokyo Social Events via photo pin cc

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