Let’s get right to it with a truthful inquiry: Do you chart your sessions? If not, why not? If my experience with the unfortunate rarity of massage therapists who conduct a thorough health history intake is any indication of the number of therapists who are charting, the answer to the question is likely no. My goal, then, is to provide a wake-up call and perspective shift by illuminating the what, the why, and the how of SOAP charting, along with the possible consequences of skipping this essential step of your overall session.
The What
Charting (also called documenting) involves keeping a clinical record of the important details and facts about a client session, specifically a problem-focused session. While other methods have been developed, the SOAP (Subjective, Objective, Assessment, and Plan) format remains the most widely used among health-care professionals.
Session details and facts include what a client says they are experiencing in their body and environment, what you see and feel when you observe and touch them, what you do during the session to address their concerns, and what your recommended plan is for making progress toward the client’s goals.
With that said, let me make a very important point: even if you are a wellness-based massage therapist whose primary focus is stress relief and relaxation rather than clinical concerns, you still need to be documenting each and every session. The SOAP format can be used with less detail, because if you are doing a proper intake, you will still be asking what the client is experiencing and what they want from the session, observing their body language and posture, and noting what techniques were used within the massage. If you prefer a format other than SOAP for documenting a wellness session, go for it. The call to action here is “Just do it!”
The Why
No call to action is complete without some critical thinking. Let’s face it, the likelihood you will surrender to the call on my urging alone is low (rightfully so). So, let’s look at a few (of many) reasons why it is so important to chart a massage session.
It promotes client safety and satisfaction. Safe therapists engage in behaviors that protect the well-being of their clients. When you listen to and chart their concerns, their limitations, their pain levels, their stress levels, what stressors they experience, what techniques they liked or didn’t like, what depth of pressure they responded favorably to and in what areas, what techniques promoted the best results, and what exacerbated a condition or concern, you are priming yourself to provide a safe and effective environment for them on an ongoing basis. This is a cornerstone of exceptional, client-focused service.
It promotes consistency and communication among other health-care professionals. Even if you don’t currently work with other health-care professionals, what if someday you do? A client may present with a concern that worsens. Having a record of when the complaint began and how it progressed could be useful information for anyone who works with this client in the future. Of course, if you already work with a health-care team, it keeps everyone on the same page toward a common goal.
It reveals progress. By documenting what you did and what changes the client experienced, you can plan future sessions more effectively by repeating what worked or changing course when an approach didn’t provide relief. Again, even if you don’t take a clinical approach, you might incorporate breathing or visualization techniques, essential oils, hot or cold packs, etc. All of these are worthy of observing the benefit. Plus, when you can show a client progression, their attitude toward the possibility of further progress supports their journey toward health.
It protects the therapist in the event of a liability claim. Most liability claims involve a client’s word against a therapist’s word. But word alone is not enough. Being able to show in a professional, thorough, well-documented manner what occurred on the date of the session in question may save you from paying a claim for which you might otherwise have been found negligent. Not to mention, if you haven’t documented a session, the likelihood you would remember the date in question is low, especially if it occurred years prior. A little time spent charting now could save you a lot of time, money, and anguish in the future.
The How
SOAP, again, is an acronym for Subjective, Objective, Assessment, and Plan. Concerns have been raised in the massage therapy profession regarding the use of SOAP charting, most notably a lack of understanding of the meaning and use of each section of the SOAP form. In an effort to create consistency, the following overview is adapted from Hands Heal: Communication, Documentation, and Insurance Billing for Manual Therapists, 5th edition (Thompson, 2019). I highly recommend this book for complete information on session documentation, from start to finish.
Subjective Data (what the client tells you)
Health History. A SOAP chart for an initial session will include health history information along with current concerns gathered from the intake form and client interview. Subsequent sessions will record changes from the previous session and ongoing status of current concerns.
Symptoms. This includes the location, onset, duration, frequency, and intensity of the symptom(s). If the client is in pain, note their precise level of pain on a measurable pain scale. It’s also of significant value to document emotional implications of these symptoms.
Functional Limitations. This refers to the limitation of daily activities, including cooking, cleaning, job performance, child care, sleeping, walking, grocery shopping, exercising, etc., due to their current concern and associated symptoms. Include activities that both aggravate and relieve their symptoms.
Objective Data (what the practitioner observes before and after the session)
Visual and Palpation Assessments. Visual includes breathing patterns, movement patterns and restrictions, postural asymmetry, and overall vitality. Palpation includes tissue texture, tone, temperature, and hydration.
Special Movement Tests. This may include gait assessment, range of motion assessment, or orthopedic assessments within scope of practice (such as Phalen’s test for carpal tunnel syndrome).
Method of Treatment. Report what techniques were used, where specifically you used them, to what depth, and for what duration.
Client Immediate Treatment Response. Note if the quality of tissue changed, if skin coloration changed, if heat increased or decreased, and/or if range of motion improved, for example.
Assessment Data (precise functional goals and analysis of treatment effectiveness toward those goals)
If a client reports during the subjective data section that they can only stand up to cook dinner for 15 minutes before their pain increases from a four to a seven on a 0–10 pain scale, their goal might be to increase that time to 20 or 30 minutes within a six-week period of weekly treatments. Chart progress toward that goal here based on what you performed in the objective data section.
Plan (practitioner recommendation for ongoing treatment and self-care)
This might look like “Weekly 30-minute massage to low back and hips for six weeks. Apply ice to low back 3 times a day for 10 minutes each round.”
The Lowdown
I recognize paperwork isn’t fun, but it is necessary. It will make you a safer and more effective therapist, keep your client on track toward a healthy and vital life, and cover your bum should anything go wrong.
There may be inconsistencies between sources on what gets documented under which heading, or if a different method of charting is more useful. In the end, though, as long as client concerns, symptoms, and goals, and practitioner pre- and post-treatment findings, approaches, and recommendations are measured and recorded in a clear and concise manner, the session will be well documented. If working with a health-care team and you are in doubt of their preferred format, just ask.
Since 2000, Cindy Williams, LMT, has been actively involved in the massage profession as a practitioner, school administrator, instructor, curriculum developer, and mentor. She maintains a private practice as a massage and yoga instructor. Contact her at cynthialynn@massagetherapy.com.