What Are SOAP Notes?

SOAP notes are clinic notes, or charting written by therapists. Not all massage therapists use charting; it depends on the venue. Spas and massage chains usually do not.

SOAP notes are written after the client leaves; they help us to review the session and keep track of what we have done, what works and what doesn't and it is a place to record client preferences. (i.e., 'likes heated table and deep pressure...)

From the National Institutes of Health:

SOAP notes are a structured method used by healthcare and behavioral health providers to document patient visits and ongoing care. The acronym stands for Subjective, Objective, Assessment, and Plan, providing a clear and uniform framework for clinical record-keeping. [1, 2, 3]

My SOAP notes are in HIPAA-compliant industry-standard digital encryption.

Massage Therapy SOAP Note Example:

Client: Julietta Bogus Fakename

Date: August 9, 2026

Therapist: Larry Healinghands Pro

Session Duration: 60 Minutes

S - Subjective (Client's Report)

• Chief Complaint: Client reports ongoing tightness in the lower back and right shoulder blade area.

• Pain Scale: Rates lower back pain as a 5 ÷ 10 and scapular tension as a 3 ÷ 10 at rest.

• Aggravating Factors: Discomfort increases after sitting at a desk for 4+ hours.

• Alleviating Factors: Client notes temporary relief from light stretching and applying a heat pack.

• Goals: Reduce muscle tension in the lumbar area to sit comfortably through the workday.

O - Objective (Therapist's Observations)

• Posture/Alignment: Noticeable forward head posture and elevated right shoulder.

• Palpation Findings: Hypertonicity and palpable trigger points in the right upper trapezius and bilateral lumbar erector spinae.

• Range of Motion (ROM): Cervical rotation limited to \(45\degree\) to the left (vs. \(60\degree\) to the right); lumbar flexion restricted by tight erectors.

• Treatment Provided: Performed 30 minutes of deep tissue massage on lumbar erectors and quadratus lumborum. Applied 15 minutes of myofascial release (MFR) and trigger point therapy to the right scapula.

A - Assessment (Therapist's Analysis)

• Impression: Muscular hypertonicity and myofascial pain resulting from prolonged sedentary desk work.

• Response to Treatment: Tissue responded well to MFR; client experienced localized muscle guarding initially, which reduced by 50% post-treatment.

• Progress: Making good progress toward reducing tissue tension.

P - Plan (Future Actions & Self-Care)

• Session Focus: Continue releasing the right shoulder and pectoral muscles in the next session to correct the elevated shoulder posture.

• Frequency: Recommend a 60-minute therapeutic massage once a week for the next 3 weeks.

• Home Care: Advise the client to perform seated levator scapulae stretches and doorframe chest stretches daily. Instructed on basic ergonomic adjustments for desk setup.