Running a flourishing massage therapy calls for more than just a dynamite technique. Depending on how you choose to run your business, successful results can get achieved at any given time. One of the significant ways you can improve your organization’s efficiency is through using soap notes for massage therapy.

What are soap notes, and why do massage therapists use them?

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. SOAP notes are a documentation method used by healthcare providers to organize their patient’s documents.

Let us look at an overview of how to make soap notes for massage therapy.

Subjective                             

Commence by documenting the information you receive directly from your patients and not from your interpretations or assumptions. It could include:

1. The patient’s critical complaint- What the patient brings in in their own words
2. The history of the patient’s current illness, as reported by them. To make your notes as subjective as possible, the information should get included using the acronym OPRST. It means:

• The Onset of the patient’s symptoms
• Any Provoking factors
• The Region of the body affected and the presence of any radiation
• How Severe the patient’s symptoms are
• The course of Time of the symptoms experienced by the patient

1. The medical history of the patient, including their past surgical and surgical history, family history, or even their social history
2. A list of the patient’s medications, including their frequency of administration and doses

Objective

The next section of your soap notes for massage therapy should compromise the objective information you gather from the patient’s encounter.

1. Begin with their vital signs. Record their heart rate, temperature, respiratory rate, blood pressure, and oxygen saturation.
2. Perform a physical exam such as on their eyes, head, ears, throat, and even on their nose. Perform respiratory, neurological, cardiac, and abdominal exams. And include any results of any other tests you might have performed.
3. Report the results of the tests done above.

Assessment

Once you’ve completed the subjective and objective parts of your soap notes for massage therapy, you ought to report your assessment.

You can do this by crafting a summary of the patient’s age, medical history, any critical clinical stability, and diagnosis.

If the patient is going through any sudden symptoms, you need to include a varying diagnosis as well. Aim to factor in at least a few possible diagnoses.

Plan

Soap notes for massage therapy get concluded with a plan.

1. You need to come up with a list of all the medical problems experienced by the patient.
2. Propose a plan on how to manage each problem identified
3. If taking care of an inpatient, be keen to note their code status, disposition, and even their deep vein thrombosis.

Reasons massage therapists use soap notes.

1. These notes help to efficiently access or locate any patients’ information.
2. The soap notes for massage therapy help to identify problems and come up with strategies for arriving at the desired goal in the treatment procedure
3. Soap notes are professional and help to build credibility and trust with the patient.
4. The notes give a clear idea to the massage therapists about the patient’s condition and in the diagnosis of any problems
5. Soap notes for massage therapy come in handy when communicating with insurance companies since the more objective data you can provide, the better.