SOAP Notes
What are SOAP Notes?
A good therapist should be able to look beyond memory. They need to know what you reported, what they observed, how you responded to treatment and what they planned to check next. SOAP Notes provide a simple structure for recording that information.
“You said my shoulder was tight last time. Do you remember what we did?”
If your therapist takes notes before or after an appointment, they are building a clearer picture of your progress. The goal is to make each visit relevant to what is happening now, while keeping track of what has changed since your last visit.
What are SOAP Notes?
SOAP stands for Subjective, Objective, Assessment and Plan. It is a common way for healthcare professionals to organise clinical notes. Each part answers a different question.
S — Subjective
What does the client report? | “My neck feels stiff when I turn to the left.”
O — Objective
What does the therapist observe or assess? | Left neck rotation appears more limited than right during today’s assessment.
A — Assessment
What do those findings suggest for this session? | Movement remains uncomfortable; a gentler approach and reassessment are appropriate.
P — Plan
What happens next? | Record the treatment provided, discuss suitable next steps and check neck movement again at the next visit.
These sections work together. A symptom you describe helps guide the assessment; the assessment informs the treatment; and your response helps shape the next plan.
Your therapist cannot feel your pain for you. That is why your description matters.
You might explain when an issue started, which activities make it better or worse, how it affects sleep or exercise, and whether anything has changed since your previous appointment. You do not need to use anatomical terms. “It hurts when I look over my shoulder while driving” is often more useful than trying to guess which muscle is responsible.
Also mention symptoms that seem different from your usual pattern. A therapist can then consider whether massage is appropriate or whether another health professional should assess you.
The objective section records relevant findings from the session. Depending on the concern and the therapist’s scope of practice, this may include observed movement, a simple functional task, tenderness during assessment or your response to a technique.
“Objective” does not mean that a therapist can prove the cause of pain by touching one spot. It means they record what they assessed or observed as clearly as possible. Your experience still matters, even when a movement test looks normal.
In the Assessment, the therapist connects your report with the findings that matter for treatment. They may note that a movement has improved, that an area remains sensitive or that today’s approach needs adjusting. This is a working clinical interpretation, not automatically a medical diagnosis.
The Plan makes the next step clear. It may include the treatment agreed upon, a change in pressure or technique, advice within the therapist’s scope, a point to reassess next time or a recommendation to seek another professional opinion when appropriate.
For example, if deep pressure increased soreness after your previous session, recording that response helps you and your therapist choose a different approach. More pressure is not a measure of better care.
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What a useful SOAP Note might look like?
Imagine you have returned to running and booked an appointment because your calf feels uncomfortable afterward. A brief note might read:
S: Client reports calf discomfort after longer runs, beginning two weeks ago. Walking is comfortable today.
O: Client completes a comfortable calf raise. Reports tenderness in one area during assessment.
A: Current findings support a cautious treatment approach. Response to running and treatment should be monitored.
P: Agree on comfortable treatment pressure. Recheck the reported activity and symptoms at the next visit; advise further assessment if symptoms worsen or do not improve.
This is only an illustration. A real note should reflect the individual appointment, the therapist’s findings and the requirements of their profession.
A note creates continuity. If you see the same therapist again, you do not have to rely entirely on remembering what happened weeks ago. It also gives both of you something specific to review: Did the painful movement change? Was the treatment comfortable? Did the benefit last? Did a new symptom appear?
That does not guarantee a particular result. However, accurate notes can support better conversations and more thoughtful adjustments to your care. Professional guidance for physiotherapy documentation likewise describes clinical notes as a record of assessment, treatment and ongoing clinical decisions.
No. Speak in your own words about what you are experiencing and what you hope to do more comfortably. Your therapist is responsible for turning relevant information into a useful clinical record.
Yes. Tell them how long the soreness lasted, how it affected you and whether the original problem changed. That information can guide the next session.
No. SOAP is a format for organising information. Writing an assessment in a note does not give a massage therapist the ability to diagnose a condition outside their scope of practice.
The detail should fit the appointment and applicable professional requirements. A first assessment, a change in symptoms and a routine follow-up may call for different information. What matters is that the record accurately explains the care provided and the decisions made.
Your Body Talks. Learn to Listen.
A note is the start of a better conversation
Your therapist’s notes are most useful when you can speak openly. Tell them what has changed, what did or did not help, and what feels comfortable during treatment. SOAP Notes then help turn that conversation into a record that can guide the next step.
Ask it. Even if you think it’s a ridiculous question.
Someone else has probably wondered exactly the same thing.
