Massage Therapy SOAP Notes: Complete Guide for Licensed Massage Therapists
Master professional massage documentation with this comprehensive SOAP notes guide. Learn how to document sessions effectively with real examples, templates, insurance billing tips, and massage-specific terminology. Essential for LMTs and CMTs.
Massage Therapy Documentation Guide
Professional SOAP Notes for LMTs
Why Massage Therapists Need SOAP Notes
Professional documentation is essential for licensed massage therapists, whether you work in a medical setting, spa, or private practice. SOAP notes provide a standardized method to record client sessions, track progress, and meet legal and insurance requirements.
Insurance Reimbursement
Required for billing medical massage to insurance companies with proper CPT codes and diagnosis
Medical Referrals
Physicians require detailed documentation to refer patients and track treatment outcomes
Legal Protection
Comprehensive records defend against liability claims and demonstrate professional standards
Continuity of Care
Session notes ensure consistent treatment and track progress over time
Professional Standards
Documentation demonstrates competency and adherence to scope of practice
Treatment Planning
Notes help identify patterns, adjust techniques, and set measurable goals
Documentation Standard for LMTs
Most state massage therapy boards require therapists to maintain session records for each client. SOAP notes satisfy legal requirements while providing clinical value for treatment planning and communication with other healthcare providers.
SOAP Format for Massage Therapy
The SOAP format adapts perfectly to massage therapy documentation. Here's what to include in each section specific to massage practice.
Subjective
Client-reported information about pain, tension, goals, and areas of concern
What to Document:
- Chief complaint (pain location, duration, intensity)
- Aggravating/relieving factors
- Activities that worsen symptoms
- Previous injuries or surgeries
- Stress levels and sleep quality
- Goals for the session
- Contraindications or health conditions
Example:
Client reports chronic tension in upper trapezius bilaterally, rated 7/10, worse at end of workday. Works at computer 8-10 hours daily. Previous car accident 2 years ago with whiplash. Current stress level 8/10. Goal: reduce neck/shoulder tension and improve range of motion.
Objective
Therapist observations including palpation findings, tissue quality, and measurements
What to Document:
- Visual assessment (posture, skin condition, swelling)
- Palpation findings (trigger points, adhesions, tissue texture)
- Range of motion measurements
- Muscle tone and tissue temperature
- Tender points and referral patterns
- Postural deviations observed
- Gait analysis if applicable
Example:
Visual: Forward head posture, elevated right shoulder. Palpation: Multiple active trigger points in bilateral upper trapezius, levator scapulae, and suboccipitals. Moderate adhesions in right SCM. Tissue feels dense, ropy. ROM: Cervical rotation limited to 60° bilaterally (normal 80°). Tender points reproduce client's familiar pain pattern.
Assessment
Clinical interpretation of findings and treatment effectiveness
What to Document:
- Tissue changes observed during session
- Response to techniques applied
- Progress toward treatment goals
- Effectiveness of treatment plan
- Clinical reasoning for approach
- Patterns identified
Example:
Client presenting with upper crossed syndrome pattern consistent with prolonged desk work. Myofascial trigger points in upper trapezius refer pain to temporal region. Tissue responded well to neuromuscular therapy and myofascial release. Noticeable decrease in muscle hypertonicity post-treatment. ROM improved to 70° rotation bilaterally.
Plan
Treatment continuation, home care recommendations, and follow-up scheduling
What to Document:
- Recommended frequency of sessions
- Home care exercises or stretches
- Self-care techniques (ice, heat, rest)
- Lifestyle modifications
- Ergonomic recommendations
- Next session focus areas
- Referral to other providers if needed
Example:
Recommend bi-weekly sessions for 4 weeks to address chronic holding patterns. Home care: gentle neck stretches 2x daily, heat before stretching. Ergonomic assessment of workstation recommended. Apply ice to upper traps if inflamed after session. Follow-up in 2 weeks; will focus on deeper work if tissue tolerance improves. Consider referral to chiropractor if ROM doesn't improve.
Complete Massage Session Examples
Here are detailed SOAP note examples for common massage therapy sessions. Use these as templates for your own documentation.
Swedish Relaxation Massage
SUBJECTIVE ----------- Client reports high stress from work deadlines and difficulty sleeping. Rates overall tension 6/10. No specific pain complaints. No contraindications. States "I just need to relax." Previous massage 6 months ago. Pressure preference: medium to firm. OBJECTIVE --------- Visual: Breathing shallow and rapid initially. Minimal postural deviations. No visible inflammation or bruising. Palpation: Generalized muscle tension throughout, most notable in shoulders, low back, and jaw. No trigger points identified. Tissue feels moderately tense but pliable. Vital signs: Client's breathing deepened and slowed within 15 minutes of session start. Techniques Used: - Effleurage: Full body, rhythmic, medium pressure - Petrissage: Shoulders, gluteals, calves - kneading and compression - Gentle stretching: Shoulders, hips, ankles - Tapotement: Brief percussion on back muscles ASSESSMENT ---------- Client achieved deep relaxation state during session (evidenced by slowed breathing, muscle softening, and verbal feedback). Generalized muscle tension decreased noticeably. Client reports feeling "like jello" and "completely relaxed" post-session. No adverse reactions. Treatment goals achieved: stress reduction and relaxation. PLAN ---- Client to schedule maintenance sessions monthly for stress management. Home care: practice deep breathing exercises 5 minutes daily before bed, Epsom salt bath 2x weekly. Recommended 10-minute walk daily to reduce stress. Next session: continue full-body relaxation focus unless specific concerns arise.
Deep Tissue for Lower Back Pain
SUBJECTIVE ----------- Chief complaint: Chronic low back pain for 3 years, rated 7/10 today. Pain increases with prolonged sitting and bending forward. Relief with movement and heat. Previous PT 1 year ago with temporary improvement. Recent MRI: mild disc bulge L4-L5, no herniation. Physician cleared for massage. Goal: reduce pain and increase mobility. Currently taking ibuprofen as needed. OBJECTIVE --------- Visual: Anterior pelvic tilt, increased lumbar lordosis. Right hip appears higher than left when standing. Palpation: - Bilateral quadratus lumborum extremely hypertonic with multiple trigger points - Right iliopsoas tender and shortened - Bilateral piriformis tight, right > left - Thoracolumbar fascia restricted, lacks elasticity - Multifidi muscles weak and atrophied at L4-L5 ROM: Forward flexion limited to 45° (normal 90°), pain at end range. Side bending 20° left, 15° right. Techniques Used (60 min low back/hips, 30 min full body): - Sustained pressure to QL trigger points (8-12 min per side) - Myofascial release: thoracolumbar fascia, IT band - Deep stripping: erector spinae group, QL - Pin and stretch: iliopsoas, piriformis - Cross-fiber friction: erector attachments at sacrum - Muscle energy technique: hip flexors ASSESSMENT ---------- Multiple myofascial trigger points in QL referring pain to SI joint region - consistent with client's reported pain pattern. Shortened hip flexors contributing to anterior pelvic tilt and compensatory lumbar hyperextension. Tissue extremely dense initially; responded well to sustained pressure with gradual softening. Client reports pain decreased from 7/10 to 3/10 post-treatment. Forward flexion improved to 60°. Right piriformis remains significantly restricted. PLAN ---- Recommend weekly sessions for 4-6 weeks to address chronic compensatory patterns, then reassess. Home care: - Prone hip flexor stretch 2 min each side, 2x daily - Supine piriformis stretch 30 sec x 3 each side - Use tennis ball for self-myofascial release on QL - Ice low back if soreness develops within 24 hours - Avoid prolonged sitting; stand/walk every 30 min Next session: Continue addressing QL and hip flexor restriction, begin strengthening focus for core stability. May recommend consultation with corrective exercise specialist if postural patterns persist.
Sports Massage - Pre-Event
SUBJECTIVE ----------- Client running half-marathon in 3 hours. Reports feeling slight tightness in hamstrings and calves but no pain. Last training run 2 days ago, tapered this week. Previous marathons x 3. No current injuries. Request: "loosen up my legs without making me too relaxed." Prefers firm pressure. OBJECTIVE --------- Visual: Athletic build, no asymmetries noted. Skin warm to touch in lower extremities. Palpation: Bilateral hamstrings moderately tense, responsive. Calves (gastrocnemius and soleus) tight but supple. Quadriceps well-toned, minimal tension. No trigger points or adhesions detected. Tissue feels warm, pliable, ready for activity. Techniques Used: - Brisk effleurage: entire lower extremity, distal to proximal - Petrissage: hamstrings, quadriceps, calves - rapid kneading - Compression: rhythmic pumping to major muscle groups - Jostling: hamstrings and quadriceps to reduce tone - Tapotement: vigorous percussion to stimulate - Active-assisted stretching: hip flexors, hamstrings, calves - Friction: brief, to increase circulation Pace: Rapid and stimulating throughout. No sustained holds. ASSESSMENT ---------- Pre-event treatment successfully increased circulation and prepared muscles for activity. Hamstring and calf tension normalized. Client reports feeling "loose and energized." Tissue temperature increased. No areas of concern identified that would impair performance. Client tolerated brisk techniques well. Treatment goals achieved: optimize performance readiness without inducing relaxation. PLAN ---- Client instructed to perform dynamic warm-up stretches 20 minutes before race start. Hydrate well. Post-race: ice any painful areas within 2 hours, schedule recovery massage within 48 hours. Recommended post-event session to address muscle soreness and facilitate recovery. Next appointment scheduled for 2 days post-race.
Massage Therapy Terminology
Use professional terminology in your SOAP notes to demonstrate clinical knowledge and communicate effectively with other healthcare providers.
Common Massage Techniques
Common Muscle Groups
Cervical Region
Upper trapezius, levator scapulae, scalenes, SCM (sternocleidomastoid), suboccipitals
Shoulder Girdle
Trapezius, rhomboids, serratus anterior, pectoralis major/minor, deltoids
Back
Erector spinae, latissimus dorsi, quadratus lumborum, multifidi, spinalis
Gluteal Region
Gluteus maximus/medius/minimus, piriformis, TFL (tensor fasciae latae)
Lower Extremity
Quadriceps, hamstrings, adductors, gastrocnemius, soleus, tibialis anterior
Upper Extremity
Biceps, triceps, forearm flexors/extensors, rotator cuff group
Insurance Billing Documentation
Medical massage can be billed to insurance when properly documented. Here's what you need to know for successful reimbursement.
Medical Necessity Documentation
Insurance requires clear documentation that massage is medically necessary, not for general wellness
- Link treatment to specific diagnosis (ICD-10 codes)
- Document functional limitations and measurable goals
- Include physician prescription or referral when required
- Show objective measurements (ROM, pain scale, palpation findings)
- Demonstrate progress toward functional outcomes
CPT Codes for Massage
Common Current Procedural Terminology codes for billing massage therapy
- 97124 - Massage, one or more areas; each 15 minutes
- 97140 - Manual therapy techniques (mobilization/manipulation)
- 97112 - Neuromuscular reeducation
- 97110 - Therapeutic exercises (when combined with massage)
- Document time spent and techniques used for each code
Required Elements for Insurance
Critical documentation components for insurance reimbursement
- Date of service and duration of treatment
- Specific techniques used and body regions treated
- Patient response to treatment (objective changes)
- Progress notes showing improvement or explaining plateaus
- Plan of care with frequency and duration of treatment
- Reassessment dates and outcome measurements
Insurance Documentation Checklist
Common Documentation Mistakes to Avoid
These frequent errors can lead to insurance denials, legal liability, and unprofessional practice.
Vague or subjective descriptions
Avoid:
Client felt better after the massage.
Better:
Client reported pain decreased from 7/10 to 3/10. ROM increased from 45° to 60° cervical rotation. Trigger points in upper trapezius showed decreased reactivity to palpation.
Why it matters: Insurance and legal protection require objective, measurable outcomes, not general impressions.
Missing contraindication screening
Avoid:
No documentation of health conditions or medications.
Better:
Intake form completed. No contraindications reported. Client not taking blood thinners, no recent surgeries, no areas of inflammation or infection. Cleared by physician for massage therapy.
Why it matters: Failure to screen for contraindications is a liability risk and standard of care violation.
Not documenting client discomfort
Avoid:
Proceeding without noting when client reports pain during session.
Better:
Client reported sharp pain when deeper pressure applied to right piriformis. Pressure reduced immediately. Switched to gentle myofascial release technique. Client tolerated modified approach well with no further discomfort.
Why it matters: Documents appropriate response to client feedback and protects against claims of injury.
Copying previous session notes
Avoid:
Using identical SOAP note from previous session without reassessment.
Better:
Perform fresh assessment each session. Document actual findings even if similar: "Findings similar to previous session: upper trapezius remains hypertonic bilaterally, though client reports 20% improvement in daily tension levels."
Why it matters: Copy-paste documentation may miss changes in condition and suggests inadequate assessment.
Lacking specific techniques and areas
Avoid:
Full body massage performed.
Better:
Techniques: Swedish effleurage and petrissage to entire posterior body (40 min), focused neuromuscular therapy to bilateral upper trapezius and levator scapulae (15 min), myofascial release to IT bands bilaterally (5 min).
Why it matters: Specific documentation is required for insurance billing and demonstrates professional treatment approach.
No home care or treatment plan
Avoid:
Session ended with no recommendations or follow-up plan.
Better:
Home care: ice right shoulder if soreness develops, perform prescribed stretches daily, avoid overhead activities for 48 hours. Recommend weekly sessions x 4, then reassess. Next appointment scheduled for [date].
Why it matters: Treatment plan shows clinical reasoning and supports medical necessity for insurance.
Massage Therapy SOAP Note Template
Use this comprehensive template for your massage therapy session documentation. Customize it to fit your practice needs.
MASSAGE THERAPY SOAP NOTE ========================= Date: ___________ Time: ___________ Duration: ___________ Client: ____________________ Session #: ___________ Therapist: ____________________ LMT #: ___________ SUBJECTIVE ---------- Chief Complaint/Areas of Concern: Pain Level (0-10): _____ Location(s): _____________________ Onset/Duration: _______________ Aggravating Factors: _______________ Relieving Factors: _______________ Previous Injuries/Surgeries: Current Health Conditions: Medications: __________________ Contraindications: [ ] None [ ] See below Client Goals for Session: Pressure Preference: [ ] Light [ ] Medium [ ] Firm [ ] Deep OBJECTIVE --------- Visual Assessment: Posture: Skin Condition: Areas of Inflammation/Swelling: Palpation Findings: Muscle Tone: Trigger Points Identified: Location(s): Active/Latent: Referral Pattern: Adhesions/Restrictions: Tissue Temperature: Tissue Quality: Range of Motion (if applicable): Joint: __________ Measurement: __________ (Normal: __________) Techniques Used (with time): [ ] Effleurage _____ min - Area(s): _____ [ ] Petrissage _____ min - Area(s): _____ [ ] Friction _____ min - Area(s): _____ [ ] Trigger Point Therapy _____ min - Area(s): _____ [ ] Myofascial Release _____ min - Area(s): _____ [ ] Neuromuscular Therapy _____ min - Area(s): _____ [ ] Stretching (active/passive) _____ min - Area(s): _____ [ ] Other: _____________________ _____ min Areas Treated (be specific): Primary Focus (time): Secondary Areas (time): ASSESSMENT ---------- Clinical Findings/Patterns Identified: Tissue Response to Treatment: Progress Toward Goals: Changes from Previous Session: Client Feedback During/After Session: Adverse Reactions: [ ] None [ ] See below PLAN ---- Home Care Recommendations: [ ] Ice (duration/frequency): [ ] Heat (duration/frequency): [ ] Stretches: [ ] Self-massage techniques: [ ] Activity modifications: [ ] Other: Recommended Session Frequency: Focus for Next Session: Referrals (if needed): [ ] Physician [ ] PT [ ] Chiropractor [ ] Other: _____ Next Appointment: ___________________ BILLING INFORMATION (if applicable) ----------------------------------- ICD-10 Code(s): ___________ CPT Code(s): ___________ Total Treatment Time: _____ minutes Insurance Authorization #: ___________ Therapist Signature: _________________________ LMT Date: ___________
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Try PatientNotes FreeFrequently Asked Questions
What should be included in massage therapy SOAP notes?
Massage therapy SOAP notes should include: Subjective (client complaints, pain level, goals), Objective (palpation findings, trigger points, ROM measurements, techniques used), Assessment (tissue response, progress toward goals, clinical reasoning), and Plan (home care recommendations, follow-up frequency, next session focus). Always document contraindications screened and any adverse reactions.
How long should massage therapists keep client records?
Most states require massage therapists to retain client records for at least 3-7 years from the last session. Some states require longer retention periods. Check your state massage therapy board regulations for specific requirements. For minors, records typically must be kept until they reach age of majority plus additional years.
Can massage therapy be billed to insurance?
Yes, massage therapy can be billed to insurance when medically necessary and prescribed by a physician. Common scenarios include treatment for injuries, chronic pain conditions, or post-surgical rehabilitation. Documentation must demonstrate medical necessity, include specific diagnosis codes (ICD-10), use appropriate CPT codes (typically 97124), and show measurable progress toward functional goals.
What is the difference between wellness and medical massage documentation?
Wellness massage documentation focuses on relaxation and general well-being, while medical massage requires more detailed clinical documentation including diagnosis, specific measurable findings (trigger points, ROM, pain scales), treatment goals, progress tracking, and outcomes. Medical massage documentation must demonstrate medical necessity for insurance billing and typically involves physician referrals.
How do I document trigger points in massage therapy notes?
Document trigger points by noting: specific muscle location (e.g., "right upper trapezius"), whether active or latent, referral pattern if present (e.g., "refers to right temporal region"), reactivity level, and response to treatment. Example: "Active trigger point in right upper trapezius, 2 inches lateral to C7, refers pain to temple. Initially very reactive, decreased reactivity after 8 minutes sustained pressure."
What techniques should I document in massage therapy notes?
Document all techniques used with specificity: effleurage (long gliding strokes), petrissage (kneading), friction (deep circular or cross-fiber), trigger point therapy, myofascial release, stretching, etc. Include duration, pressure level, and body areas treated. For insurance billing, specify time spent on each technique and relate it to treatment goals.
How often should massage therapists write SOAP notes?
SOAP notes should be written for every client session, ideally immediately after the session while details are fresh. For insurance billing, notes are mandatory for each visit. Even for wellness clients, session notes create a treatment history, track progress, demonstrate professional standards, and provide legal protection.
What are common contraindications to document in massage notes?
Always screen and document contraindications including: acute injuries or inflammation, infectious conditions, fever, blood clots or clotting disorders, uncontrolled hypertension, recent surgery, cancer (without physician clearance), skin conditions in treatment area, pregnancy complications, and medications like blood thinners. Document that screening was performed and note any modifications made to treatment.
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