Massage Therapy Plan of Care

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

Date of Plan: [MM/DD/YYYY]

Therapist: [Therapist name, credentials, license/registration number]

Location/Setting: [Clinic / Home / Workplace / Other]

Episode Start Date: [MM/DD/YYYY]

Plan Review Date: [MM/DD/YYYY]

Referral Source: [Referring clinician name, date, and stated diagnosis/reason / Self-referred]

Clinical Indication

[Primary presenting complaint(s), current functional impact, and therapy intent: restorative vs. maintenance/supportive] (Limit to 1–3 sentences. Reference evaluation note for details if one exists.)

Problem List

(Prioritize and label with stable identifiers P1, P2, P3. Frame around symptoms and function rather than medical diagnoses.)

• P1: [Body region with laterality] — [Symptom/impairment descriptor] — [Associated functional limitation] — [Severity: mild/moderate/severe; Irritability: low/moderate/high]

  • Contributing factors: [Work ergonomics / Sleep position / Training load / Stress / Other] (Include only if relevant to the plan.)
  • Referring diagnosis (if applicable): [Diagnosis text]
  • Baseline measures: [Pain scale with context]; [Functional tolerance]; [Palpation or ROM findings with method noted] (If not yet obtained: "Baseline pending—will be recorded at visit #1.")

• P2: [Body region with laterality] — [Symptom/impairment descriptor] — [Associated functional limitation] — [Severity; Irritability]

  • Contributing factors: [If relevant]
  • Referring diagnosis (if applicable): [Diagnosis text]
  • Baseline measures: [Pain scale with context]; [Functional tolerance]; [Palpation/ROM findings with method] (If not yet obtained: "Baseline pending—will be recorded at visit #1.")

• P3: [Additional problems as needed following same structure]

Goals

(Link each goal to its problem number. Include metric, baseline or "baseline pending," target value, timeframe, and functional context. Prefer functional goals over tissue-quality-only goals.)

Short-Term Goals (STG)

• STG 1 (P#): [Functional goal statement]. Metric: [Metric]. Baseline: [Value or "baseline pending"]. Target: [Target value]. Timeframe: [1–4 weeks or 2–6 visits]. Context: [Activity/condition].
• STG 2 (P#): [Functional goal statement]. Metric: [Metric]. Baseline: [Value or "baseline pending"]. Target: [Target value]. Timeframe: [Time window]. Context: [Activity/condition].

Long-Term Goals (LTG)

• LTG 1 (P#): [Functional goal statement aligned with anticipated discharge]. Metric: [Metric]. Baseline: [Value or "baseline pending"]. Target: [Target value]. Timeframe: [Episode end]. Context: [Activity/condition].
• LTG 2 (P#): [Additional LTG if needed]

Planned Interventions

(Organize by problem. If technique selection is pending first-session response, state initial conservative approach.)

Plan for P1

• Target regions/structures: [Anatomic regions/structures]
• Techniques: [Effleurage / Petrissage / Myofascial release / Trigger point therapy / Neuromuscular therapy / Cross-fiber friction / Lymphatic techniques / Other]
• Intensity: [Light / Moderate / Deep] (Patient-guided threshold)
• Session time allocation: [Approximate minutes for this problem]
• Progression strategy: [Criteria to adjust intensity, regions, or techniques based on response]
• Patient education & self-care: [Stretching / Positioning / Ergonomics / Heat-cold guidance / Activity modification]
• Referral triggers: [Red flags or findings that prompt PCP/specialist recommendation]

Plan for P2

• Target regions/structures: [Anatomic regions/structures]
• Techniques: [Technique names]
• Intensity: [Light / Moderate / Deep]
• Session time allocation: [Approximate minutes]
• Progression strategy: [Criteria]
• Patient education & self-care: [Topics]
• Referral triggers: [Criteria]

Plan for P3

[Additional problem-specific plans as needed]

Treatment Dose

Visit Length: [30 / 45 / 60 / 90] minutes

Frequency: [1×/week / 2×/week / Every other week / Monthly / Other]

Planned Duration/Total Visits: [Number of visits over time period]

Taper Plan: [None planned / Frequency reduction schedule if goals progressing / Maintenance frequency after LTGs met]

Rationale: [One sentence tying dose to severity, irritability, complexity, and goals]

Precautions & Contraindications

• Absolute contraindications: [List / None identified]
• Relative precautions and modifications: [Precautions with planned technique/pressure/positioning adjustments]
• Allergies/sensitivities: [Lotions / Oils / Latex / Scents / None] — [Product alternatives if applicable]
• Areas to avoid or modify: [Specific regions with rationale]
• Screening status: [Complete / Screening pending—plan not yet ready to initiate]

Consent & Boundary Constraints

• Draping plan: [Standard draping description and any modality-specific variations]
• Sensitive area work (breast tissue, gluteal cleft, inner thigh): [Not indicated for this plan / Indicated—separate written consent obtained with exact boundaries documented]
• Consent withdrawal: [Patient informed they may withdraw consent for any area or technique at any time during session]

Reassessment Schedule

• Interval: [Every 4 weeks / Every 4 visits / Other]
• Measures to repeat: [Specific measures tied to goals]
• Early reassessment triggers: [Symptom worsening / New symptoms / No meaningful progress by visit # / Adverse response]
• Plan modifications: (Document changes with date, rationale, and signature; do not overwrite prior content.)

Discharge Criteria

• Goals met: [Reference specific LTG thresholds]
• Plateau: [No clinically meaningful improvement despite appropriate modifications]
• Intolerance/adverse effects: [Documented adverse responses]
• Non-adherence: [Missed visits or home program non-participation impacting outcomes]
• Escalation/referral: [Findings suggesting need for medical evaluation]
• Maintenance option: [Reduced frequency with periodic review schedule, if appropriate]

Signature

[Therapist signature], [Credentials] — Date: [MM/DD/YYYY] Time: [HH:MM]