"Soap Notes Template - Associated Bodywork and Massage Professionals"

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SOAP Notes
Practitioner/Clinic Name: _________________________
Contact Information: ____________________________
Client Name: __________________________________
DOB: ___________
Ins. ID#: _______________
S: (Subjective) Client reported status—goals for session, symptoms, functional limitations; Physician’s diagnosis or
description of condition
O: (Objective) Practitioner reported findings—posture, movement, palpation; and massage/bodywork application—
what you did, where you did it, for how long
A: (Assessment/Application) Client’s response to treatment—less pain, more movement, etc.; quantify results using
either a numerical scale, 0-10, or a value scale, Mild (L) moderate (M) or Severe (S)
P: (Plan) Recommendations for self-care and plan for future care
R
L
L
R
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
Key: Symbols for figures
Key: Abbreviations
Pain O
R = right
i  
Stiffness/tension
L = left
Spasm ≈
BL = bilateral
ROM = range of motion
Adhesion/Scar tissue X
Inflammation O
XFF = cross fiber friction
P = pain
Elevation or depression /
Rotated ↵ or
M = massage
HA = headache
 
MEMBER
< = less than
 
Associated Bodywork & Massage Professionals
> = greater than
SOAP Notes
Practitioner/Clinic Name: _________________________
Contact Information: ____________________________
Client Name: __________________________________
DOB: ___________
Ins. ID#: _______________
S: (Subjective) Client reported status—goals for session, symptoms, functional limitations; Physician’s diagnosis or
description of condition
O: (Objective) Practitioner reported findings—posture, movement, palpation; and massage/bodywork application—
what you did, where you did it, for how long
A: (Assessment/Application) Client’s response to treatment—less pain, more movement, etc.; quantify results using
either a numerical scale, 0-10, or a value scale, Mild (L) moderate (M) or Severe (S)
P: (Plan) Recommendations for self-care and plan for future care
R
L
L
R
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
S: _________________________________________________________________________
O: _________________________________________________________________________
A: _________________________________________________________________________
P: _________________________________________________________________________
 
Date: ______________
Duration: _______________
Key: Symbols for figures
Key: Abbreviations
Pain O
R = right
i  
Stiffness/tension
L = left
Spasm ≈
BL = bilateral
ROM = range of motion
Adhesion/Scar tissue X
Inflammation O
XFF = cross fiber friction
P = pain
Elevation or depression /
Rotated ↵ or
M = massage
HA = headache
 
MEMBER
< = less than
 
Associated Bodywork & Massage Professionals
> = greater than