When massage therapists talk about their profession, they likely share how rewarding it is to make a difference in their clients' lives. If you ask them about the least favorite part of their responsibilities, 99 percent will tell you the documentation following treatment is a pain in their neck.
SOAP notes are a necessity. Charting subjective complaints, observations, assessments and remedial plans is an integral part of the vocation of massage therapy. Therapists rely on them, governing bodies require them and insurance companies insist on them.
Between therapists, though, there seems to be some confusion about the acronym SOAP. SOAP notes are best described as the following:
S is for the clients' subjective complaints and symptoms. This includes all the things a client tells the therapist about how she is feeling, past history, present symptoms, limitations in her life due to injury, what makes her feel better or worse, and details about the initial onset of the problem or injury.
O is for the massage therapist's observations and what techniques were done during the session. This includes visual observations and physical findings discovered when palpating the client's body. Therapists should include things they observe about the client's posture, movement, weakness, level of tension in the tissues, spasms in muscles, joint movement, color and temperature of skin and breathing patterns.
A is for assessment. Massage therapists are not allowed to diagnose conditions. The assessment category serves to report the immediate results of the session. At the end of treatment, the therapist should reanalyze the posture and range of motion and make notes on any changes in symptoms using as many descriptive words as possible.
P is for plan. After treatment, the therapist should suggest a treatment frequency and things that need to be addressed in the future, in what is referred to as a treatment plan. This includes any self-care instructions given to the client, special requests by the client or reminders for the next session.
SOAP notes can be written manually or documented electronically. With paper SOAP notes, there are sometimes challenges with rereading them. In addition, if abbreviations are not consistent—especially in a clinic where multiple massage therapists practice—it can cause a lot of confusion. Also, if a physician or insurance company requests a chart, the quality of the photocopies may come into question.
Furthermore, with SOAP notes, it is essential to have a diligent filing system. Always remember to file your SOAP notes correctly.
You can also document SOAP notes using a Web-based charting program. This type of software aims to eliminate some of the arduous duties with filing paper SOAP notes.
Proper documentation protects therapists, increases professionalism and helps ensure excellent continuity of care for clients.