Massage Therapy Session SOAP Note

Client Name: [Client full name]

DOB: [Date of birth]

Date of Service: [Date]

Date of Entry: [Date] (Include only if documentation completed after date of service.)

Duration: [Total minutes]

Therapist: [Therapist name, credentials]

Visit Type: [Wellness / Therapeutic]

Subjective

[Primary concern or goal for today's session] (Use a brief direct quote when helpful. For returning clients, note relevant changes since last visit including symptom trends, new injuries or diagnoses, medication changes, and response to prior treatment or home care. Include brief health status screen for contraindications or cautions. Omit items not assessed.)

[Client preferences and boundaries] (Document pressure preference, areas to avoid, positioning needs, and any components declined. For therapeutic sessions, characterize symptoms: location, severity 0–10, quality, aggravating and relieving factors, and functional impact. Note consent status if renewed; document therapeutic rationale and draping modifications for sensitive-area treatment. Keep Subjective to 1–2 short paragraphs.)

Objective

• Observations: [Postural or movement patterns] (Include only if assessed.)
• Palpation: [Location-specific tissue findings with severity] (Include tone, tenderness, trigger points, and restrictions as relevant.)
• Range of Motion: [Active / Passive ROM findings] (Specify degrees or functional descriptors; note symptoms reproduced. Include only if assessed.)
• Treatment Rendered: [Anatomic areas treated; techniques and modalities applied; pressure or intensity level; client positioning; client tolerance and in-session responses]
• Outcome Measures: [Pre → post changes in pain scale, ROM, or functional measures] (Include when applicable.)

(Omit categories not relevant to today's session.)

Assessment

(Provide a concise clinical impression of 1–3 priority focus areas addressed today. For each, reference supporting evidence from Subjective and Objective and note client response to treatment. Indicate progress toward goals for therapeutic sessions. Document any red flags or referral considerations using observational language within scope of practice.)

• [Focus Area 1]: [Clinical impression with key supporting findings; client response and progress]
• [Focus Area 2]: [Clinical impression with supporting findings] (Include only if applicable.)
• [Focus Area 3]: [Clinical impression with supporting findings] (Include only if applicable.)
• Red Flags / Referral Considerations: [Observational findings prompting referral or further evaluation] (Include only if identified.)

Plan

• Next Session: [Priority areas with rationale; anticipated techniques or modalities; suggested frequency]
• Home Care: [Specific exercises or self-care with dose, frequency, and safety precautions] (Omit if none assigned.)
• Referrals / Care Coordination: [Recommended referrals or provider communication] (Include only if applicable.)