Massage therapy SOAP note example

A session note from a licensed massage therapist working with a runner. It records the intake check, palpation findings, the techniques and pressure used on each area, a simple before-and-after measure, and self-care advice.

Example SOAP note

Fictional client: Sam W., 36, 60-minute session, third visit. Any likeness to a real person is a coincidence.

Subjective

Client is training for a half marathon, running about 25 miles a week. Right calf tightness after long runs, 5/10 at worst and 2/10 today.

Low back stiffness in the morning that eases with movement. No numbness, recent injury or new medications; health intake reviewed with no changes and no contraindications reported.

Prefers firm pressure on the legs, moderate on the back. Goal: recover between long runs.

Objective

Palpation: hypertonicity of the right medial gastrocnemius and soleus, with a trigger point in the medial gastrocnemius referring to the back of the knee.

Lumbar erector spinae (both sides) and right quadratus lumborum hypertonic and tender, 6/10 under pressure.

Knee-to-wall test before treatment: right 8 cm, left 11 cm.

Treatment, 60 minutes: Swedish and deep tissue to the back of the legs (25 minutes); trigger point compression to the right medial gastrocnemius, 3 rounds of 60–90 seconds; myofascial release to the lumbar area and right quadratus lumborum (20 minutes); Swedish to the upper back and neck (10 minutes). Pressure moderate to firm, within the client's comfort.

After treatment: knee-to-wall right 10 cm. Client rated the calf 1/10.

Assessment

Good tissue response: less tone in the right calf and lower back, ankle dorsiflexion improved by 2 cm. Pattern fits his current training load.

No adverse reaction during or after the session.

Plan

Self-care: calf stretches with the knee straight and bent, 30 seconds three times on each side after runs; foam roll the calves for 2 minutes; drink water after today's session.

Next session in two weeks, before his race taper; focus on the right calf and lower back.

See a physician or physical therapist if calf pain turns sharp, lasts more than a week or causes limping.

Why this note works

  • The intake check and contraindications are documented before treatment.
  • Findings are specific to muscles and sides, with a tenderness rating.
  • Each area has its technique, minutes and pressure, so the next therapist can repeat or adjust it.
  • A before-and-after measure (knee-to-wall) shows the session's effect.
  • The Assessment records findings and response rather than a medical diagnosis, which is outside a massage therapist's scope in most states.

What to include in each section

Subjective

  • Reason for the session and areas of concern
  • Pain or tension rating (0–10) and what affects it
  • Health intake changes, medications and contraindications
  • Pressure preference and areas to avoid
  • Client's goal

Objective

  • Posture and range of motion observed
  • Palpation findings by muscle and side: tone, tenderness, trigger points
  • Techniques, areas, minutes and pressure
  • Before-and-after measures
  • Client's response during the session

Assessment

  • Tissue response and change after the session
  • Progress since the last session
  • Any adverse reaction

Plan

  • Self-care: stretches, heat or ice, hydration
  • Next session date and focus
  • Referral to another provider when needed

Write yours with the free SOAP note template

The template opens with the massage therapy prompts. Fill it in and download a PDF, made on your device.

Open the template

SOAP notes in CloudMedico

CloudMedico is practice management software for small practices. Choose SOAP as your visit note format in Practice settings, and every new visit's notes open with the headings Subjective, Objective, Assessment and Plan. Practices in the United States start with SOAP.

Add the visit's diagnoses from the ICD-10-CM list, and add your own visit fields for what your profession records every time, such as a pain scale or the regions treated. Each visit stays on the client's record with their appointments and invoices, and a US practice can make a superbill from the invoice.

Try CloudMedico free for 30 days

More SOAP note examples

Questions

Do massage therapists need to write SOAP notes?

Many state boards require session records, and insurers, personal injury cases and workers' compensation ask for them. SOAP notes are the usual format, and they help you follow a client's progress between sessions.

Can a massage therapist write a diagnosis in the Assessment?

In most states massage therapists aren't licensed to diagnose. Record your findings and the client's response instead, and if a physician gave a diagnosis, note it as theirs.

How detailed should a massage SOAP note be?

Enough to repeat the session: the areas treated, the techniques, the minutes, the pressure, what you found and how the client responded.

Sources

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