In the practice of Chiropractic, Physiotherapy, massage therapy and other heath care disciplines it is important that the documentation of client problems and treatment history be consistent, concise comprehensive and up to date. Many health care practitioners use the SOAP Note format to standardize their patient records.
SOAP is an acronym that stands for Subjective observations, Objective observations, Assessment and Plan.
The purpose of the SOAP Note is to document the patient’s condition and record their progress after each massage session. SOAP Notes can help the therapist track the effectiveness of treatment techniques and to determine whether or not the treatment need to be adjusted in future sessions to better address the patient’s problem areas.
The four parts of a SOAP Note are described below.
This initial portion of the SOAP note is made up of subjective observations. These are symptoms the patient verbally expresses to the practitioner. The subjective observations should include the client’s descriptions of:
It is helpful for the practitioner to ask the patient to rate their pain or discomfort on a level 1-10 with 10 being the worst. This allows the practitioner to see improvements or setbacks as time goes on.
This part of the SOAP Note is the objective observations. These objective observations include symptoms that the massage practitioners can actually see or feel. The subjective observations should include the practitioner’s observations about the patient:
It is also useful to test the patient’s range of motion in different areas and track their changes from session to session.
Practitioners use this part of the SOAP Note to document the immediate results of a treatment. At the end of a session the practitioner reanalyzes and documents the changes in the client’s posture and range of motion. This part of the report should indicate the amount of change that occurred by ranking the progress – None, Mild, Moderate or Significant.
The last part of the SOAP Note is the treatment plan. The plan should include: