Key Takeaways
- SOAP notes are the standard documentation format: Subjective, Objective, Assessment, Plan
- Subjective data comes from the client (symptoms, pain level, history, goals)
- Objective data comes from the therapist (observations, palpation findings, ROM measurements, postural assessment)
- Assessment is the therapist's clinical interpretation of the subjective and objective data
- Plan documents the treatment performed and recommendations for future sessions
- Informed consent must be obtained before treatment and includes risks, benefits, alternatives, and right to refuse
- Treatment plans should include measurable goals, frequency of sessions, and expected timeline
- Scope of practice defines what massage therapists are legally allowed to do — they cannot diagnose, prescribe, or perform adjustments
Treatment Planning & Documentation
Professional documentation protects the massage therapist, the client, and ensures continuity of care. SOAP notes are the industry standard for healthcare documentation used by massage therapists.
SOAP Notes
SOAP is an acronym for the four components of a clinical note:
S — Subjective
Information reported by the client. This includes:
- Chief complaint: "I have pain in my lower back"
- Pain description: Location, intensity (0-10 scale), quality (sharp, dull, burning, aching)
- History: When the pain started, what makes it better or worse, previous treatments
- Goals: What the client hopes to achieve from massage therapy
- Activities: Work, hobbies, sleep patterns, stress levels
- Medications: Current medications and supplements
- Changes since last session: Better, worse, or unchanged
O — Objective
Information observed or measured by the therapist. This includes:
- Visual observations: Posture, gait, skin condition, swelling, bruising
- Palpation findings: Muscle tone, texture, temperature, tenderness, trigger points, adhesions
- Range of motion: Active ROM, passive ROM, pain with movement
- Special tests: Orthopedic tests performed (within scope)
- Treatment provided: Techniques used, areas treated, duration, products applied
A — Assessment
The therapist's clinical interpretation of the subjective and objective data:
- Summary of findings and their significance
- Progress toward treatment goals
- Response to previous treatments
- Clinical reasoning for the chosen approach
- Example: "Client presents with increased upper trapezius hypertonicity bilaterally, consistent with reported desk work stress. ROM improved from last session."
P — Plan
Future treatment recommendations:
- Recommended frequency and duration of sessions
- Techniques to use in next session
- Self-care recommendations (stretches, exercises, ice/heat, ergonomic changes)
- Referrals to other healthcare providers if needed
- Timeline for reassessment of progress
Informed Consent
Informed consent must be obtained before any treatment and includes:
- Nature of the treatment: What massage techniques will be used
- Benefits: Expected positive outcomes of the treatment
- Risks: Potential side effects (soreness, bruising, emotional release)
- Alternatives: Other treatment options available
- Right to refuse: The client can stop treatment at any time
- Confidentiality: How client information will be protected
- Financial: Fees, cancellation policy, insurance information
Important: Informed consent is an ongoing process, not a one-time event. The client can withdraw consent at any time during the session.
Treatment Planning
Components of a Treatment Plan
| Component | Description | Example |
|---|---|---|
| Goals | Specific, measurable outcomes | "Reduce lower back pain from 7/10 to 3/10" |
| Frequency | How often sessions should occur | "Twice per week for 4 weeks, then weekly" |
| Duration | Length of each session | "60-minute sessions" |
| Techniques | Methods to be used | "Swedish massage, trigger point therapy, myofascial release" |
| Self-care | Home recommendations | "Daily stretching, ergonomic workstation setup" |
| Reassessment | When to evaluate progress | "Reassess after 4 sessions" |
| Timeline | Expected duration of care | "8-12 sessions over 3 months" |
SMART Goals
Treatment goals should be SMART:
- Specific — clearly defined outcome
- Measurable — quantifiable (pain scale, ROM degrees)
- Achievable — realistic for the client
- Relevant — related to the client's concerns
- Time-bound — defined timeline for achievement
Scope of Practice
Massage therapists are legally allowed to:
- Perform massage and bodywork techniques
- Assess soft tissue conditions through palpation
- Recommend stretches, exercises, and self-care
- Use hot/cold therapy and hydrotherapy (in most states)
- Communicate findings to other healthcare providers
Massage therapists are NOT allowed to:
- Diagnose medical conditions
- Prescribe medications or supplements
- Perform spinal adjustments or manipulations
- Order medical tests (X-rays, MRIs, blood tests)
- Provide psychological counseling or therapy
- Practice beyond their training (e.g., acupuncture without certification)
Special Populations
Prenatal Massage
- Positioning: Side-lying is the preferred position after the first trimester (avoid prolonged supine positioning which can compress the inferior vena cava)
- Contraindications: Pre-eclampsia/eclampsia, placenta previa, threatened miscarriage, high-risk pregnancy
- Benefits: Reduces back pain, leg cramps, swelling, stress, and anxiety
- Precautions: Avoid deep abdominal work, reduce pressure on the legs (increased DVT risk during pregnancy), avoid certain acupressure points traditionally associated with labor induction
- Always obtain physician clearance for high-risk pregnancies
Geriatric Massage
- Considerations: Thinner skin, decreased bone density (osteoporosis), decreased circulation, more medications
- Technique modifications: Lighter pressure, shorter session duration, avoid deep tissue on fragile tissues
- Benefits: Improved circulation, reduced pain and stiffness, decreased isolation and depression, improved sleep
- Precautions: Position changes should be slow; watch for orthostatic hypotension; check for skin fragility
Oncology Massage
- Definition: Massage specifically adapted for clients with cancer (during or after treatment)
- Key principles: Lighter pressure, avoid radiation sites, avoid areas near ports/devices, avoid lymph node areas if nodes have been removed
- Benefits: Reduced anxiety, improved sleep, decreased pain, reduced nausea
- Requirements: Specialized training is strongly recommended; always coordinate with the client's oncology team
- Contraindications: Active tumor sites, areas of known metastasis, unstable blood counts (thrombocytopenia)
Sports Massage
- Pre-event: Light, brisk strokes to warm muscles and increase circulation; avoid deep tissue work; 10-15 minutes
- Post-event: Gentle, calming strokes to promote recovery; light stretching; reduce muscle soreness; 15-30 minutes
- Maintenance: Regular sessions between events; deeper work on specific problem areas; injury prevention
- Rehabilitation: Targeted work on injured areas (post-acute phase); coordinated with sports medicine team
In SOAP notes, which section contains information reported by the client?
A massage therapist observes that a client has increased muscle tone in the upper trapezius and reduced cervical ROM. Where should this be recorded?
Which of the following is outside the scope of practice for a massage therapist?
Informed consent is best described as:
Match each SOAP note section to its correct content.
Match each item on the left with the correct item on the right
Treatment goals should follow the SMART framework: Specific, Measurable, Achievable, Relevant, and ___-bound.
Type your answer below
A client asks their massage therapist whether they should take ibuprofen for their pain. The therapist should:
During a prenatal massage, what is the preferred position for a client after the first trimester?
Which of the following is a SMART treatment goal?
What type of massage is specifically adapted for clients who are undergoing or have completed cancer treatment?
Match each hydrotherapy application to its primary physiological effect.
Match each item on the left with the correct item on the right