Why Use SOAP Notes as a Massage Therapist

SOAP notes are medical documentation for a treatment; a type of progress report used by massage therapists to document a patient’s condition and progress during treatment. These are used and required for medical massages when insurance or claims are involved. Medical insurance sessions, worker’s compensation claims, auto-accident claims, and VA patients are examples of situations requiring SOAP notes.

SOAP is an acronym, which stands for:

“S” – Subjective Complaints (what the patient says is wrong with them – reason for visit)

“O” – Objective Findings (what you see and feel – posture, muscle tension, ROM)

“A” – Assessment (patient’s response to treatment and the therapist’s interpretation and findings of “S” and “O”)

“P” – Plan (what will happen next – future sessions/goals, at-home exercises)

It can take some time to learn how to write these properly – ensuring you put the correct information with the appropriate category or letter, but with examples, templates, and practice, you will become a Pro at these in no time.

If you’re thinking you won’t ever do medical insurance sessions or any of the above-listed ones where SOAP notes are required, keep in mind there are many situations when having SOAP notes for fee-based clients (non-insurance clients) will be important to have.

It’s an important practice to learn and incorporate SOAP notes with clients as it trains you to logically follow an order with how to proceed with your massage client’s care – documenting what they say is bothering them, what you noticed about their posture, what you felt and assessed during the massage, what massage techniques and stretches you performed on them, and ultimately reporting the progress the client is or is not making and then offering a plan on how to continue treatment and at-home care.

I learned how to do SOAP notes in 2005 when I worked with a physical therapist. I did the medical massage aspect of the physical therapy treatments, and because we billed medical insurance for those sessions, SOAP notes were required. Honestly, at first, I was not thrilled about needing to document each patient session in this way. Back in the day (when we trudged through snow to get to school and did not have on-demand anything), the SOAP notes I wrote had to be in paragraph form. Now with all the amazing scheduling systems and automation, there are much easier SOAP note options for massage therapists where you can check off boxes and have bullet-point lists – all digitally. Bless.

I wrote about 25 SOAP notes per week for a decade (over 500,000!), so I became well-versed in the structure and concepts of these notes, and I came to appreciate how they trained my brain to approach patient care – from the communication we get from the patient, to detailing out my observations of the patient, to then assessing what I discovered during the treatment, connecting with the patient on how they felt post-treatment, and then to follow up with them with a plan. It’s a solid, logical approach to patient care that extends into every massage client you work with – whether a medical insurance massage patient or a fee-paying massage client.

SOAP notes are used by many, different medical providers – not just by massage therapists, of course. Doctors, nurses, physical therapists, psychologists, and social workers all need to write SOAP notes for each of their patient sessions. If someone is billing insurance, the insurance companies will require to see and to evaluate these notes to ensure the money they pay for the sessions is being used correctly – ultimately that what they are paying for is working and benefitting the patient. It makes sense, right?

As a massage therapist, if you see fee-based clients, meaning they pay you directly and there’s no other company that is paying you for the service, you do not have to do SOAP notes, but it’s still a good practice to be aware of and know how to do – so you’re thinking and planning their care in this logical structure.

If you’re billing insurance for massage sessions, you are required by the insurance company to keep SOAP notes. If you don’t have these notes, you may not get paid for those services. The same is true if you take worker’s compensation patients – for you to receive money from that company for the patient’s massage sessions, you will need to keep these SOAP note documentations for each visit. The same is true for auto-accident claims and VA benefit patients.

SOAP notes, for medical or non-medical sessions, are also a smart idea so that you have better legal protection. It’s easier to think that nothing negative will ever happen to one of your clients because you think you would never do anything to harm someone. But that is not realistic because everyone can make a mistake at some point. By following a logical structure with your note keeping (and ultimately how you handle client care), interestingly, the note process will help you avoid issues with clients because of the structure you’re using to approach each session.

Also, it might not be that you made a mistake but that the client thinks you’re responsible for something that happened to them. They could do something after seeing you for a massage that injures them, but they think you’re the cause of that. With proper notes and a thorough health intake, you can be better protected from such situations.

For example, say that you see a fee-based client (not insurance) and that you incorporate hot stones into your massage session. You have notes about the inclusion of this heat therapy and that the client reported he felt very relaxed from the session and he tolerated the hot stones well (meaning, there weren’t any issues from using the stones – the client never had any redness beyond normal limits from the stones, the client never reported anything being too hot – and also in their health intake form, there were no reasons not to use the stones…no neuropathy or diabetes reported, which could limit the client’s sensation of heat and could cause a burn to happen in that area because the client could not feel if it’s too hot or not). The client leaves very happy and relaxed – no issues – all documented.

You then hear from that client 5 days later, and they claim you burned them with the hot stones on their foot. They send you a picture of their big toe that looks red and inflamed and has blisters. Yes, you should have liability insurance as a licensed massage therapists (a state requirement in Colorado), but you also need to have notes supporting what you did for that session for your liability insurance company to best help you if that client were to try and sue you for the medical care and damages to their toe.

Also, as you get busy with your massage practice, you will see many clients and patients each week, so you need to keep track after the session (or at least by the end of the work day) with your notes for that session so you don’t forget what you did, how the client responded, and what you recommended for them.

If you didn’t have notes of this hot stone client and 5 working days later, you might not remember what you saw. Memory is not reliable so having notes will save you much stress long term if any negative situation like this arises in the future.

This hot stone client example was a real one for me. Thankfully, I was keeping SOAP notes for all clients at that time because I also had insurance patients that I was required to keep SOAP notes for. I was very grateful I had my notes for his session and his health intake form that I reviewed with him in detail at the beginning of the session. My intake process and SOAP note writing saved me much headache long term (an ounce of prevention is worth a pound of cure).

With this client, I asked him what activities he did after seeing me for his massage (from leaving my treatment room to the day he emailed me). This client went skiing the next day after seeing me for a session. He was visiting in town and had to use new ski boots, which is atypical for him when skiing. I’m not sure why he didn’t connect his toe blisters and inflammation to the ski boots but chose to blame me and his hot stone treatment with me instead. Not everyone approaches things logically – in many cases – they don’t.

Along with emailing him this question, I let him know that I reviewed his intake form and saw no contraindications for using hot stones with him, and I confirmed with him (via email, in writing) that he did not have a condition like diabetes or neuropathy (he didn’t mark those on his intake form, but some people forget things, so I wanted to re-confirm that).

I explained my take after reviewing his health history and my session notes and said that he did not have any redness on his feet when leaving my treatment and he never reported during the session that the heat was too much for him, so I don’t see how his toe issues could be from my session. I explained that I could easily see how he could get blisters and redness/inflammation from ski boots that are new and don’t fit him well and wearing those for several days. Ultimately, he agreed with me, and we didn’t have to take it further with insurance or claims, which is always preferable.

Having these detailed notes and a thorough health intake helped both of us review the situation more logically and accurately and saved me from future legal issues.

Yes, it’s easier not to do SOAP notes if you don’t have to, but they will make your sessions more therapeutic and targeted, which often means more directed and dialed-in care for the client, and then you will also safe-guard yourself from potential legal issues that could arise.

Many companies offer digital SOAP note options that are integrated well into your scheduling software. I highly recommend you and your massage business start using these immediately for all your sessions, insurance, and fee-based. Along with the items mentioned above, when clients feel listened-to and well-treated (you’re addressing their concerns and helping them with those concerns) that will also turn into increased client retention and referrals, which means increased profits as well. Win-Win all around.

This article was written by our founder and owner, Hillary Hilliard. She has been a Massage Therapist since 2004 and an Herbalist since 2010. She teaches classes for all of our programs: Herbalism Roots, the Denver Integrative Massage School, and the School of Botanical & Medical Aesthetics. Hillary loves being connected with all aspects of her schools, and she’s very grateful for these opportunities to share her passion and love for the healing arts and the beauty arts with as many people as possible.

View Program Information

Enrollment Information