SOAP Note Example
Massage Therapy SOAP Note Example
Below is a complete SOAP note example for a 60-minute massage therapy session treating chronic lower back pain. Each section is broken down with explanations of what to include and why.
Complete Massage Therapy SOAP Note
SUBJECTIVE:
Client presents with chronic lower back pain of 3 weeks duration, aggravated by prolonged sitting at work. Pain rated 6/10, described as a dull ache in the lumbar region. No radiating symptoms to lower extremities. Client reports pain is worse at the end of the work day and partially relieved by standing and walking. No history of acute injury. Previous treatment: OTC ibuprofen with minimal relief.
OBJECTIVE:
Palpation revealed bilateral hypertonicity in the lumbar paraspinal musculature, particularly at L4-L5. Active trigger points identified in the quadratus lumborum bilaterally, right greater than left. Myofascial adhesions noted along the thoracolumbar fascia. Limited active ROM in lumbar flexion (approximately 60% of normal). Tenderness at the SI joint bilaterally. Treatment: Deep tissue massage applied to lumbar paraspinals (20 min). Trigger point therapy to QL bilateral with sustained pressure and release technique (10 min). Myofascial release to thoracolumbar fascia (10 min). Swedish effleurage to full back for integration (10 min). Stretching: passive lumbar rotation and hip flexor stretch bilateral. Treatment performed in prone and sidelying positions. Total session: 60 minutes.
ASSESSMENT:
Client presents with myofascial restriction and chronic muscular tension in the lumbar region consistent with postural strain from prolonged sitting. Partial release achieved in QL trigger points bilaterally — right side more resistant than left. Lumbar ROM appeared slightly improved post-treatment (not formally measured). Client reported pain decreased to 4/10 immediately following session. Condition is expected to respond well to a series of treatments combined with ergonomic modifications and home stretching.
PLAN:
Recommended follow-up massage therapy session in 2 weeks focusing on continued QL trigger point work and lumbar paraspinal release. Home care instructions: lumbar extension stretches (cobra/sphinx) 2x daily, hip flexor stretches (kneeling lunge) 2x daily, 30 seconds each. Heat therapy to lower back 15-20 minutes as needed for pain relief. Advised client to set hourly standing breaks during work day. Ergonomic desk assessment recommended. Goal: reduce pain to 2/10 and restore full lumbar ROM within 6 sessions.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
This section captures the client's own report of their condition. Note the specifics: duration (3 weeks), aggravating factors (sitting), pain rating (6/10), quality (dull ache), location (lumbar), and what they've tried (ibuprofen). This gives anyone reading the note a clear picture of why the client is there.
Objective
This is where you document what YOU found and what YOU did. Include specific muscles, anatomical landmarks, and techniques used. Note the time spent on each modality — this matters for insurance reimbursement and demonstrates the session was therapeutic, not just relaxation.
Assessment
Your clinical interpretation of the findings. Connect the subjective complaints to objective findings (postural strain → lumbar tension). Note the treatment response (pain went from 6/10 to 4/10) and your prognosis. This section justifies the treatment and the need for continued care.
Plan
Specific, actionable next steps. Include follow-up timing, home care with enough detail for the client to follow (exercise names, frequency, duration), and treatment goals with measurable outcomes. This demonstrates continuity of care and gives the client clear expectations.
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