Massage Therapy Re-evaluation/Progress Note

Patient: [Patient name]

DOB: [Date of birth]

Date of Service: [Date of service]

Therapist: [Therapist name], [Credentials]

Episode Start: [Episode start date]

Visit #: [Current visit number]

Reporting Period: [Date range covered / since last progress note dated _____]

Reason for Re-evaluation: [scheduled progress review / symptom change / plateau / pre-discharge / other]

Subjective

[Chief concern and current priorities]

[Interval history since last progress update] (Summarize symptom course with consistent pain scale, noting changes in location, quality, and aggravating/relieving factors. Describe functional status changes tied to treatment goals. Document response to prior massage sessions including immediate effects and duration of benefit. Include self-management adherence and any new co-interventions or medical changes. State "not assessed" for any expected information not obtained. Limit to 1–2 paragraphs.)

Objective

(Document re-check measures with prior-to-current comparisons. Specify measurement methods used.)

Pain rating: [Current rating on consistent scale with context] — Prior: [value]

ROM/mobility and functional tests: [Relevant measures tied to goals with method, prior values, and current values]

Palpation findings: [Tenderness location, tissue tone, trigger point findings in observable terms] (Avoid diagnostic certainty.)

Other findings: [Neurologic/vascular screen if indicated by red flags; any additional relevant observations; note measures not re-checked with brief rationale]

Assessment

[Clinical progress summary] (State overall trajectory: improving / plateau / worsening / variable. Specify which domains changed and whether response to massage has been transient or sustained. Identify relevant barriers if present. Provide scope-appropriate clinical impressions and skilled rationale supporting continued massage therapy when ongoing care is indicated.)

Goal Status: (List each goal with status and brief supporting evidence.)

• [Goal 1] — [Met / Progressing / Not met / Regression] — [Evidence]
• [Goal 2] — [Met / Progressing / Not met / Regression] — [Evidence]
• [Additional goals as needed] (Modify or add goals only when clinically indicated.)

Plan

Treatment: [continue / modify / discontinue] massage therapy at [frequency] for [duration/visits]; target regions: [regions]; technique intent: [relaxation / neuromuscular / myofascial / lymphatic / other]

Modifications: [Planned changes and rationale, or "none"]

Self-management: [Key education and home strategies reinforced]

Coordination: [None / coordinate with ___ / refer to ___] (Include referral triggers if relevant.)

Next re-evaluation: [Date or visit number]

Therapist Signature: [Signature] — Date: [Date] — Credentials: [Credentials]