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Obj: Visual
Obj: Testing
Obj: Palpation
Obj: Modalities



Client Focus

This field allows you to enter your client’s goals for the current session in your client’s own terms.


  •  “Roberta is seeking care for injuries sustained in a motor vehicle accident.”

  •  “Jason is looking for massage to relieve stress and ease low back pain.”

  •  “Mia is looking for relief from discomfort following her recent bone marrow transplant.”

Some Massage Therapists start this field with a summary of their client's evaluation of their health changes since the previous session. 

Example: Client reports "Neck pain and stiffness continue. But I have more mobility now and can turn my head much better. Headaches continue but much less frequently. Midback discomfort remains. I am still having difficulty sleeping but since getting the Tempurpedic Pillow, it has improved significantly."

Having some direct quote can be useful if you need to remind your patient how she was feeling during an earlier session.

Caution: Report what your client says. Not your interpretation.

Contraindications and health concerns

Enter your client’s contraindications and health concerns for the current session.


  •   “John has arthritis.”

  •  "Paulina broke her left collar bone in June and that area is still tender to touch."

  •  “Christina requests that her feet not be massaged.”

To learn more about contraindications:




Current Medications

Enter your client’s prescription drugs. Include drug name and quantity.

Example: “Naprosyn 500 mg taken twice daily”

One possible sign of progress is that a client lowers her pain medication intake as the treatment advances. Don't focus solely on the medication intake to assess progress: some times the medications stay constant, but your patients' capabilities and activities will increase dramatically.

To learn more about massage and medications:



Record your client’s symptom intensity, sensation, location, frequency, duration and onset.

Example: “Severe pain in left hip(s) radiating to left quadriceps occurring 3 to 5 times a day and lasting 3 to 5 minute(s) since Ultimate Frisbee injury.”

Progress might manifest itself by changes in intensity, sensation, location, frequency, or duration. If you don't record all of these, you might miss a chance to record progress.

Sort your symptom list by order of importance, with the most important symptom on top.

Activities of Daily Living

Record the activities that aggravate your client’s symptoms. Choose one or two activities of concern to your client that your therapy might facilitate in a 4 to 8 sessions.

Example: “Activity: Job requires standing at cash register 8 hours a day. Aggravation: Pain increases from mild to moderate after 30 minutes. Limitation: Client has to stop standing after one hour because of the pain.”

Your client is more likely to make progress if the activity you select is of immediate interest to her and is directly relevant to her everyday life. For instance, a parent would likely be more interested in lifting up her child, than in lifting up some arbitrary weight.


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

Next: The Objective section of the SOAP Notes



Home | Introduction | Therapist| Client | Session | Subjective
Objective - Visual | Objective - Palpation | Objective - Modalities | Objective - Testing
Assessment | Plan | Forms

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Last modified: 06/10/08