Reflexology Session Note (SOAP)

Client: [Client full name] — [DOB or Client ID]

Date of Service: [Date] | Start: [Start time] | End: [End time] | Hands-on duration: [Minutes]

Session Type: [foot / hand / ear / mixed] — [initial / follow-up]

Location: [Clinic / mobile / facility name]

Practitioner: [Name, credentials]

Consent: [informed consent on file and reconfirmed this session / obtained today prior to treatment / not obtained—document reason]

Safety Screen: [contraindication review completed prior to treatment / deferred—document reason and actions]

Subjective

[Client-stated primary concern or session goal] (Use client's own words when available; maintain wellness-oriented phrasing.)

[Secondary goals or areas of interest] (Include if stated.)

[Interval changes since last visit] (For follow-up sessions: summarize symptom trends, response after prior session, and health updates. Attribute diagnoses as "client reports diagnosis of …" If no changes, state explicitly: "No interval health or medication changes reported.")

[Preferences, boundaries, and tolerances] (Document desired pressure range, areas to avoid, positioning needs if stated.)

(If client cannot provide information, document why and how the session proceeded.)

Objective

Pre-treatment observations: [Skin integrity and visible findings of feet/hands/ears as applicable]

Intervention: [Technique style] — [light / moderate / firm pressure] — [areas emphasized] — [time allocation if relevant] — [products or positioning supports used]

Tolerance and response: [Observable relaxation signs, tenderness or guarding, client verbal reports during session, modifications made and rationale]

Adverse events: [Event, immediate actions taken, resolution status] (Include only if occurred.)

Assessment

[Overall session tolerance and client-reported effect by session end] (Use same measures referenced in Subjective when available.)

[Progress toward stated goals compared to prior sessions] (Use functional, symptom-focused language; note trends as [improved / stable / worsened]; avoid diagnostic terminology.)

[Rationale for any technique or pressure modifications] (Include if applicable.)

[Red-flag symptoms observed or disclosed, actions taken, referrals recommended, client understanding] (Include only if applicable.)

Plan

Next session focus: [Proposed areas, techniques, and intended modifications based on today's response]

Follow-up interval: [Proposed timeframe with brief rationale tied to goals]

Home guidance: [General wellness support recommendations with safety qualifiers] (Avoid medical treatment claims.)

Provider communication: [Communication with other providers if applicable, with client consent documented]

Signature

Practitioner: [Name, credentials] — [Signature] — [Date and time of authentication]

(General guidance: Use wellness-oriented, functional language. Attribute medical conditions as "client reports diagnosis of …" Avoid claims of treating or curing diseases. Omit items not assessed unless omission is clinically significant.)