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Introduction
Therapist
Client
Session
Subjective
Obj: Visual
Obj: Testing
Obj: Palpation
Obj: Modalities
Assessment
Plan
Forms

 

Assessment

In this section of the soap notes, massage therapists record functional goals and functional outcome.

Functional Goals

Use this section to provide long and short term goals that are:

  •  specific to a daily activity (E.g.: “walk up a flight of stairs…”)

  •  measurable, (“… made of 10 steps, 3 times a day, every day, with no more than moderate pain …”)

  •  attainable, 

  •  relevant to your client’s ability to earn a living and care for himself/herself and family.

  •  time bound (“… within 30 days.”)

Example: “Eduardo will be able to walk up a flight of stairs made of 10 steps with no more than moderate pain 3 times a day every day, within 30 days.”

Short term goals should be attainable in 2 to 4 sessions.

Long term goals should be attainable in 4 to 8 sessions.

Typically, only one long term goal and one or two short term goals are needed.

Functional Outcome

Use this section to record goals that have been achieved.

Example: “As of September 25, 2004, Eduardo is now able to walk up a flight of stairs made of 10 steps with no more than moderate pain, 3 times a day every day.”

To learn more about this subject, consult Outcome-Based Massage, by Carla-Krystin Andrade and Paul Clifford.

 

Does all this sound overwhelming?
See how your computer can give you a hand with WinCity Massage SOAP Notes.

Next: Plan

 

 

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Last modified: 10/15/08