SOAP notes have four parts:
Subjective is about how you perceive the client to be doing.
This includes how your client looks and feels and their recent activity. This section is where you’ll record things like the mechanism of injury, chief complaint, symptoms, and description of pain. It also includes the medical history, which should take up the majority of the note.
Objective is how your client is actually doing based on objective measures including a physical exam, vital signs, ins and outs, and recent results from labs, cultures, and other tests.
To make it simple it means, “The data the therapist takes from palpation.” It also means: visual-postural analysis, limps, muscle guarding, holding patterns, inconsistencies in movements, atrophy, hypertrophy, bruises, abrasions, scars, swelling, redness, skin irregularities, varicose veins, breathing patterns and prosthetics. Treatment goals can be added to define the intention of your massage choices and that they ensure that your treatment-plan has a purpose.
This is when “The therapist evaluates what she or he is doing.” Such as; Changes in client’s condition because of treatment and changes in symptoms. (Sometimes people include the application in the assessment part)
The plan is the treatment you intend to implement, including long-term treatment plans and lifestyle recommendations. It contains all the required steps, and details every proposed treatment, including therapies, and surgeries.
It should also outline a treatment plan for next session and include: what worked, what didn’t work, what you did not address, and what you want to make sure to work on next time.
If there are no changes to be noted in the assessment part, you may have ideas for next time. Recommend the client to get a massage on a regular basis: 1 x wk for 4wks.
They might not follow it but at least you tried and you are looking out for their best interest and you have it documented.
It should also include your short- and long-term goals for the client with any potential homework or exercises they should be doing.