How to Write SOAP Notes for Massage Therapy

Just like heating pads, hot stones, and essential oils, SOAP notes are an essential tool for massage therapists. In fact, they elevate the services you provide even more than those other resources. They do this by helping you document each session, track progress over time, and support personalized, consistent care.

You have a healer’s touch and a deep understanding of the musculoskeletal system. But perhaps your notetaking or documentation abilities weren’t fully developed during your massage education and certification. That’s okay. Below, we’ll break down SOAP notes section-by-section, with samples that teach you how to write massage therapy SOAP notes. You’ll also find sample SOAP notes tailored to relaxation and therapeutic massage sessions.

Introduction to Massage Therapy SOAP Notes

Massage therapy SOAP notes are a crucial component of a massage therapist’s practice, serving as a standardized method for documenting client sessions, tracking progress, and communicating with other healthcare providers.

The SOAP note format, which stands for Subjective, Objective, Assessment, and Plan, provides a clear and concise structure for recording client information, making it an essential tool for massage therapists to document a patient's:

Diagnosis
Symptoms (physical and/or emotional)
Treatment
Progress toward therapy

By utilizing SOAP notes, massage therapists can ensure that they are providing high-quality care, enhancing patient outcomes, and maintaining accurate records. This structured approach not only helps in delivering personalized treatments but also supports the continuity of care when collaborating with other healthcare professionals.

Remember that progress notes, such as SOAP notes, follow a standard format. Massage software, like Vagaro’s, offers an intuitive SOAP note feature that breaks this format down simply.

(Note: There are actually three types of SOAP notes you can add with Vagaro, which this support article explains how to use.)

Are SOAP Notes Necessary for Massage Therapists?

The SOAP framework offers a methodical approach to track a client’s healing journey. This format enables you to document client-reported discomfort, your professional palpation findings, and applied bodywork techniques.

By maintaining these detailed records, you’ll preserve essential information about tissue conditions, pressure preferences, and response patterns. This enables you to deliver personalized and effective manual therapy.

The benefits of using SOAP notes in massage therapy are numerous:

Continuation of Care: SOAP notes help massage therapists track client progress and the effectiveness of the treatment plan, and make necessary adjustments based on patient progress.
Clear Communication: SOAP notes facilitate communication with other healthcare providers. This is particularly important when clients are receiving treatments from multiple providers, such as physical therapists or chiropractors.
Organization: SOAP notes help massage therapists to stay organized, reducing the risk of errors and improving the overall efficiency of their practice.
Legal Compliance: Thorough SOAP documentation serves as professional protection, providing evidence of appropriate, standards-based care if disputes arise.
Profressionalism: By using SOAP notes, massage therapists can also demonstrate their commitment to providing high-quality care, which can lead to increased client satisfaction and loyalty.
Informed Clients: SOAP notes provide rationale for your techniques, enabling client understanding and building trust in your approach.

With that, let’s dive into what each SOAP note section entails, and how to write them.

Subjective

The subjective section of a massage SOAP note documents the client’s reported concerns and background. It captures self-described tension, pain, and bodily sensations in his or her own words. This section records consultation discussions and may include the client’s exact words.

The purpose of gathering subjective information is to identify your client’s primary areas of discomfort or concern. Keep in mind that clients may present multiple areas needing attention, and they might not immediately mention their most significant issue. Ask targeted questions about pain levels, movement limitations, stress factors, and previous bodywork experiences.

Doing so, you should uncover:

Your client’s description of muscle tension, pain, or discomfort
Physical symptoms like limited range of motion, postural issues, or tenderness
Recent activities that may be affecting your client’s muscular condition
Your client’s stress levels, exercise patterns, daily movement habits & self-care routines
Relevant health history, such as injuries, surgeries, and current medications

Remember to include only relevant information. Use direct quotes from your client or important feedback about their comfort, sensation, or response to previous treatments. Always set these quotes apart with quotation marks.

Objective

The objective section records observable and measurable client data. Massage therapists use it to document physical findings during assessment and treatment.

Physical examination findings are part of the objective observations made by healthcare professionals when documenting patient care.

As a bodywork professional, note things like the client’s:

Posture
Movement patterns
Tissue quality
Muscle tone
Areas of tenderness
Visible signs like redness or swelling

Stick to factual observations. Document only what you can see, feel, or measure through techniques like range of motion testing, postural assessment, and palpation findings without introducing personal interpretations or judgments.

Assessment

The Assessment section integrates subjective reports and objective findings to detail the patient's condition. It helps form your clinical impression of the client’s musculoskeletal condition.

This section may include a summary of the client’s discomfort patterns and relevant physical history. You can document your professional insights on tissue quality, movement restrictions, and areas of dysfunction. Also, include progress toward therapeutic goals like increased range of motion or reduced pain levels.

Plan

The Plan section of your SOAP note outlines upcoming steps in your client’s massage treatment. This field should include specific bodywork techniques to be applied, treatment areas requiring focus, and recommended session frequency.

A detailed massage therapy plan is crucial for tracking the client's progress and ensuring thorough documentation for insurance billing.

Document your intended pressure levels, modalities (such as deep tissue, myofascial release, or trigger point therapy), and any supplementary approaches like hot stone or cupping. Include short-term goals (reducing specific trigger points) and long-term objectives (improving overall shoulder mobility). List any self-care recommendations such as stretches, hydrotherapy, or movement practices for between sessions.

How To Write SOAP Notes

Now let’s put everything together. Here is a simple example of what SOAP notes may look like for a massage therapist. Note the specific details and the language used.

Date/Time: May 14th, 2025, 1 p.m.

Client Name: Melissa Greene

Therapist Name: Rose Walker

Session Length: 60 minutes

Subjective

Client, Melissa G., complains of tension headaches and upper back discomfort. She says, "My shoulders feel like they're up to my ears all day long, and I can't seem to relax them." She reports increased stiffness after long workdays at the computer, saying, "I notice the pain gets worse by Wednesday each week."

Melissa reports that the headaches have been occurring daily for the past two weeks and are often accompanied by neck stiffness. She rates the pain as a 6 out of 10 and mentions that it worsens in the afternoon.

We discussed his workplace ergonomics, stress levels, daily movement patterns, and how these factors might be contributing to his muscle tension and discomfort.

(In this example, the massage therapist records the client's self-reported symptoms and lifestyle context. The client's description of her symptoms, including frequent headaches and neck pain, provides essential context for effective diagnosis and treatment.)

Objective

During the intake, Melissa presented with observable data such as elevated shoulders and a forward head posture, suggesting postural strain. Noticeable muscle tension was observed in the upper shoulders and along the neck.

Gentle palpation revealed areas of tightness in the upper trapezius and along the sides of the neck, with sensitivity noted near the right shoulder blade. Range of motion in the neck was slightly limited when turning to the right, compared to the left. Melissa expressed mild discomfort when moderate pressure was applied to the base of the skull, indicating possible tension in the suboccipital area.

(In this example, the massage therapist records the client’s observable physical presentation and assessment findings. These details provide objective evidence of the client’s musculoskeletal condition.)

Assessment

Based on Melissa’s self-report and the therapist’s clinical findings during the session, the client appears to be holding tension related to ongoing stress, particularly in the neck, shoulders, and lower back. Melissa mentioned experiencing restlessness and occasional difficulty sleeping, which may be contributing to overall muscle fatigue and reduced relaxation.

The therapist’s impression is that while these concerns are not currently severe, they are impacting Melissa’s ability to fully unwind and may benefit from regular massage therapy to support relaxation, improve sleep quality, and promote overall wellness.

(In this example, the therapist reviews the client’s self-reported concerns and physical presentation during the session. They use this information to form a professional impression of the client’s overall wellness and areas of muscular tension or stress.)

Plan

Melissa will continue receiving therapeutic massage weekly to support relaxation, reduce muscular tension, and improve posture. Sessions will focus on the neck, shoulders, and upper back, with gentle work around areas of sensitivity. The therapist recommended integrating light stretching and posture awareness between sessions, and Melissa agreed to try a short evening routine to help unwind before bed.

Follow-up appointments are crucial for ensuring continuation of care, evaluating the effectiveness of the treatment plan, and making necessary adjustments based on patient progress.

Together, they discussed the potential benefits of restorative movement, such as yoga or walking outdoors, to complement massage and support stress relief. Melissa expressed interest in exploring guided relaxation or breathwork, which may be introduced in future sessions if she feels comfortable.

The therapist will continue to build rapport and monitor Melissa’s areas of tension, adjusting techniques as needed to ensure comfort and progress toward her wellness goals

(The example notes the recommended frequency and duration of massage sessions. Include both short- and long-term wellness goals, such as reducing tension, improving sleep, or enhancing relaxation. If applicable, list any suggested self-care practices between sessions, such as gentle stretches, hydration, or mindfulness exercises.)

Disclaimer: These examples are intended for educational purposes only. Please consult your state licensing board or legal counsel for specific documentation requirements related to your massage therapy practice.

SOAP Notes Checklist for Massage Therapists

You might be wondering if SOAP notes are essentially the same for all massage therapists. The short answer is—mostly, but not exactly.

While the basic SOAP structure remains consistent, the details and emphasis within each section may vary depending on the therapist’s approach, the setting (spa, clinical, or mobile), and the client’s specific goals or needs.

For example, in a spa setting, SOAP notes may focus more on relaxation, stress relief, and client comfort, while clinical notes might place greater emphasis on range of motion, injury recovery, or chronic pain management.

Writing effective SOAP notes is a crucial component of patient care and documentation. It ensures that each session is tailored to the client's unique needs and wellness goals.

Whatever your modality or specialty us, follow these key guidelines when writing SOAP notes:

Make your SOAP notes concise, objective & relevant to your patient’s treatment plan. Straightforwardness makes for clear communication and accurate client records – both of which are essential for effective care.
Ensure accuracy of dates, times, names & tenses. Avoid obscure abbreviations or colloquialisms. Use terminology recognized in the massage and adjacent wellness fields. You are potentially not the only person who may need to reference your SOAP notes.
Be consistent. Use a standardized SOAP note format, making it easier to review and compare notes over time.
Always attribute patient statements with quotation marks and qualify subjective statements with evidence.
Don’t erase or remove errors. Rather, use a strikethrough, identify that spot as an “error,” and correct it.
Avoid moral judgments when describing your patient (i.e., if you think they “stubbornly refuse to stop physically compromising exercises” that they are “clearly too old to be doing.”)
Write your SOAP notes promptly after the session to ensure accuracy and completeness. Take an extra few moments to review them when finished. (Scheduling software often.

By following these best practices, massage therapists can ensure that their SOAP notes are effective, efficient, and provide valuable insights into client care.

HIPAA Compliance

As healthcare providers, massage therapists are required to comply with the Health Insurance Portability and Accountability Act (HIPAA). HIPPA regulates the handling of protected health information (PHI). When creating and storing SOAP notes, massage therapists must ensure that they are following HIPAA guidelines, including:

Using secure and encrypted digital storage solutions,
Limiting access to authorized personnel
Obtaining client consent before sharing PHI with other healthcare providers

By prioritizing HIPAA compliance, massage therapists can protect client confidentiality, maintain trust, and avoid potential legal and financial consequences. Ensuring that all documentation practices align with HIPAA standards not only safeguards client information but also reinforces the therapist’s professionalism and commitment to ethical practice.

Proper client documentation not only reflects your professionalism as a therapist but also helps ensure each session is tailored to your client’s unique needs and wellness goals. While keeping SOAP notes may feel repetitive at times, they play a key role in providing consistent, high-quality care.

Vagaro’s HIPAA-compliant practice management software makes it easy to create, store, and access SOAP notes and other client documentation. Notes are securely saved to each client’s profile, so you can quickly reference session history and track progress over time.

Going paperless with Vagaro’s digital forms and EMR tools helps streamline your workflow—so you can spend less time on admin and more time caring for your clients. Start your 30-day trial, and experience everything else it can do for your business.