SOAP Notes in Seconds

SUBJECTIVE:
Client presents with chronic lower back pain that has been exacerbated by prolonged sitting at a desk. The client rates the pain as 6/10 on the pain scale, describing it as a dull, persistent ache localized to the lumbar region. No radiating symptoms reported.

OBJECTIVE:
Upon palpation, hypertonicity was noted in the L4-L5 paraspinal musculature bilaterally. Limited range of motion observed in lumbar flexion. Tenderness reported at the sacroiliac joint bilateral. Deep tissue massage was applied to the lumbar paraspinals. Trigger point therapy performed on the quadratus lumborum bilaterally with notable release. Myofascial release techniques applied to the thoracolumbar fascia. Treatment performed in prone and sidelying positions. Session duration: 60 minutes.

ASSESSMENT:
Client presents with myofascial restriction and muscular tension in the lumbar region consistent with chronic postural strain. Partial release achieved in trigger points of the QL. ROM slightly improved post-treatment. Client reports pain decreased to 4/10 following session.

PLAN:
- Follow-up massage therapy session recommended in 2 weeks
- Client advised to perform lumbar stretching exercises 2x daily
- Heat therapy recommended for home use, 15-20 minutes as needed
- Ergonomic desk assessment suggested to address postural contributing factors