Sports Massage Session Note

Client: [name/ID per facility policy]

DOB: [date of birth] (Include per facility policy)

Date/Time: [session date, start time]

Location: [clinic, training room, event venue]

Practitioner: [name, credentials]

Session Type: [pre-event / post-event / maintenance / recovery / symptom-focused / other]

Sport/Activity: [sport, position/role if relevant, level (recreational/competitive/elite), training phase]

Event Context: [event name, timing relative to event, key demands expected] (Include only if session is event-linked)

Safety & Consent

• Informed consent obtained: [yes / no]
• Areas authorized for treatment: [list]; Areas excluded by client request: [list or none]
• Contraindications screen: [no contraindications reported or observed / specific concerns noted]
• Referral/escalation status: [no referral indicated / referral recommended to [provider] for [reason] / urgent evaluation advised for [reason]]
• Sensitive area treatment consent: [verbal / written / chaperone present]; chaperone: [name/role] (Include only if sensitive area treatment performed; document per jurisdictional requirements)
• Red flag(s) noted: [findings]; advice provided: [description]; client response: [description] (Include only if red flag present)

Subjective

[Brief narrative linking chief concern to sport/activity context]

• Mechanism and training context: [onset, overuse pattern, workload changes, aggravating/easing factors]
• Symptoms: [location with laterality, quality, severity 0–10, stiffness/cramping, numbness/tingling if present]
• Functional limitations: [task-specific impacts relevant to sport/activity]
• Goals: [session goals and short-term goals]
• Interval changes: [response to prior session and changes since last visit] (Include for follow-up visits)

Objective

(Document only findings from today's assessment. Use consistent anatomical terminology and laterality.)

• Observation: [posture, gait, protective behaviors, visible swelling/bruising, skin integrity]
• Palpation: [tenderness mapped to landmarks, tissue tone/density, trigger points, temperature change, client response]
• Movement/functional checks: [AROM limitations, sport-task tolerance] (Include only if performed)
• Baseline measure: [pain pre-session 0–10 and/or function rating]
• Objective testing deferred due to: [reason] (Include if applicable; do not imply normal findings for unassessed areas)

Assessment

[2–3 sentence synthesis connecting sport context, mechanism, objective findings, and functional impact. Use scope-appropriate, non-diagnostic language; reference any existing diagnoses from other providers as history. Note if findings suggest need for referral.]

Problem list: [prioritized list of problems, e.g., 1) R calf tenderness limiting sprints; 2) L hip flexor tone affecting stride]

Plan

Treatment Performed

• Body regions treated (with laterality): [list]
• Techniques used: [techniques]; duration/allocation: [time per region or total]
• Pressure intensity: [light / moderate / deep]
• Areas intentionally avoided: [area] – [rationale] (Include if applicable)
• Adjuncts/modalities: [e.g., assisted stretching, instrument-assisted, taping] (Include only if used)

Response

• Pain change: [pre 0–10] → [post 0–10] (Include if measured)
• Functional/task tolerance change: [description]
• Tissue reactivity and client tolerance: [description]
• Adverse events: [none / description]

Self-Care

• Hydration/recovery guidance: [advice within scope]
• Mobility suggestions: [gentle movements within scope]
• Expected responses and warning signs: [what to monitor; when to seek care]
• Equipment/technique adjustments: [recommendations] (Include if applicable)

Return-to-Activity

(Frame as recommendations, not medical clearance, unless credentialed to clear)

• Participation status: [full / modified / hold]
• Activity modifications: [specific drills, volume/intensity limits, timing]
• Stop rules: [symptoms that should prompt stopping activity]
• Escalation/coordination: [who to contact if concerns arise; communication with AT/PT/physician if applicable]

Follow-Up

• Next session: [date/timeframe]; focus: [regions/goals]
• Referrals/coordination planned: [details] (Include if applicable)

Practitioner Signature: [name, credentials]

Date/Time Signed: [date/time]

Late entry: [statement per policy] (Include only if documentation completed after the encounter)