SOAP Notes Help w/ example

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SOAP Notes Help w/ example

Postby gpcmassage on Sat Jul 12, 2008 8:41 pm

I did a search and haven't really found anything that answers my question so I am going to try a new post. I currently use SOAP notes for my charting on all clients. I use pretty much the same form I was taught with in school, and in school they told us ALMOST every time they will be the same. Which they are, but now that I am doing quite a few auto accident cases they really aren't and I don't like my notes are. Everything seems just so repetitive. Obciously the client complaints and the outcomes of the massage are different but the rest just seems boring and the same - I alsmot feel like I am not doing my notes as well as they should be done.

SO..... my question is if anyone would be willing to give me some examples of their soap notes - obviously without any client names.

As an example of what I do now my most "repetitive" notes sound something like this....

S: clent came in for this, c/o this
O: Hypertonic areas found here, TP found here any other areas that need noting - mark areas on body diagrams
A: (here is where things feel repetitive) Cl supine. Warmed neck w/ eff. Stripped SCM, scales and upper trap. Used occiput hold on occiputs. Stretched neck mm. Warmed arms w/ eff. Stripped forarm flexors and extensors, bicep and tricep. Ended w/ compressions. Warmed front of legs w/ eff. Worked quads w/ MFR, palmar gliding, stripping & pet. Worked tibalis w/ MFR, stripped along tibalis. Ended w/ compressions. Worked feet with reflex. (state # of min depending on session length)
Cl prone. Warmed back of legs w/ eff. Worked hams w/ MFR, palmar gliding, pet. Worked gastroc & soleus w/ pet, stripping, palmar gliding, XFF & MFR. Ended w/ compressions. Warmed back w/ eff. Worked traps & rhomboids w/ MFR, XFF, vibration, stripping, palmar gliding, static pressure/TP Therapy. Worked QL's w/ MFR, pet, XFF, stripping & palmar gliding. Ended w/ compressions. Worked glutes w/ kneading. upper body mm didn't respond well, lower body mm responded well to tx. Cl stated she felt great p M.
P: Increase H2O.... do this do that.

That's pretty standard for any client coming in for a full body M, for my AA clients it's usually the same thing but they only get waist up Massage so it's shorter. Any tips or help? Like I said, if anyone is willing to share a copy of their notes to help me expand and be more explanatory that would be great. Thanks!
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Postby palpable on Sat Jul 12, 2008 9:09 pm

The book "Hands Heal" by Diana Thompson is great for SOAP notes.



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Postby Rose of Sharon on Sat Jul 12, 2008 9:37 pm

We were taught a bit differently. The only very-specific charting I do is in relation to a specific client complaint. I don't note on the swedish/relaxation portions other than to say FBS or whatever.....then regarding the specific pain, I will note what techniques I used on which specific muscles in the region and beyond the region if it is related. So.....for shoulder pain, if I find TPs in the subscap, I note the TPs and then what stretches/TPT was done. Note where/if there are other TPs, such as in pec minor, etc. and what is done for those. But for back, legs.....unrelated to the complaint/injury, I note that I did a full body swedish.
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Postby gpcmassage on Sun Jul 13, 2008 7:04 am

I have the book hands heal and it's helpful, but i still feel a bit lost. We used the book in school and the teacher hardly used it, I wish she would have went through it more because it is a great book about everything!

I like the way you do your notes, much eaiser I guess then really going into all the detail if the client really didn't have any complaints.
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Postby Patrick W on Sun Jul 13, 2008 11:22 am

mine are a little different when it comes to the "A" portion.....

S:
what the client says

O:
what i see- visual postural assessment, gait, functional movement pattners, etc...
tests- orthopedic tests, muscle length/strength tests, etc..
all other obeservations

I add in a seperate section in the "O" portion describing my treatment that day and what I did.

A:
I assess how the client responded to the treatment- IE, client responded well to treatment and commented on decreased pain and stiffness in neck musculature.
I also re-test things from the "O" section- IE, muscle length/strength tests, visual assessments, palpable assessments, functional movement patterns that have been corrected through soft tissue treatment and exercise based protocols.


P:
What my plan is for the coming treatments and what some of my goals are.



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Re: SOAP Notes Help w/ example

Postby SaraZWalker on Fri May 27, 2011 11:37 am

As noted:

The S is obviously why the client came. It should be somewhat precise so will be different. eg Stress out at work and want relaxing massage. Back hurts from golf. All my stress goes to my neck.


The O is what you find. Your exam. ef: R shoulders tight. Gluts in pain,

The A is is your assessment. Almost the same as the O. Gentleman with high stress job needs relaxing massage. Stress goes to but or shoulders and needs therapeutic.

The P: is your plan and your treatment results: For stressed out at work: perhaps will try esalen. For stiff shoulders will try hot stone...

Client fell asleep and seemed relaxed. Client did not like esalen etc

For Auto accidents and insurance, add more relating to the accident...Even O: can find no physical findings related to accident.
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Re: SOAP Notes Help w/ example

Postby JasonE on Fri May 27, 2011 11:01 pm

gpcmassage wrote:I did a search and haven't really found anything that answers my question so I am going to try a new post. I currently use SOAP notes for my charting on all clients. I use pretty much the same form I was taught with in school, and in school they told us ALMOST every time they will be the same. Which they are, but now that I am doing quite a few auto accident cases they really aren't and I don't like my notes are. Everything seems just so repetitive. Obciously the client complaints and the outcomes of the massage are different but the rest just seems boring and the same - I alsmot feel like I am not doing my notes as well as they should be done.

SO..... my question is if anyone would be willing to give me some examples of their soap notes - obviously without any client names.

As an example of what I do now my most "repetitive" notes sound something like this....

S: clent came in for this, c/o this
O: Hypertonic areas found here, TP found here any other areas that need noting - mark areas on body diagrams
A: (here is where things feel repetitive) Cl supine. Warmed neck w/ eff. Stripped SCM, scales and upper trap. Used occiput hold on occiputs. Stretched neck mm. Warmed arms w/ eff. Stripped forarm flexors and extensors, bicep and tricep. Ended w/ compressions. Warmed front of legs w/ eff. Worked quads w/ MFR, palmar gliding, stripping & pet. Worked tibalis w/ MFR, stripped along tibalis. Ended w/ compressions. Worked feet with reflex. (state # of min depending on session length)
Cl prone. Warmed back of legs w/ eff. Worked hams w/ MFR, palmar gliding, pet. Worked gastroc & soleus w/ pet, stripping, palmar gliding, XFF & MFR. Ended w/ compressions. Warmed back w/ eff. Worked traps & rhomboids w/ MFR, XFF, vibration, stripping, palmar gliding, static pressure/TP Therapy. Worked QL's w/ MFR, pet, XFF, stripping & palmar gliding. Ended w/ compressions. Worked glutes w/ kneading. upper body mm didn't respond well, lower body mm responded well to tx. Cl stated she felt great p M.
P: Increase H2O.... do this do that.

That's pretty standard for any client coming in for a full body M, for my AA clients it's usually the same thing but they only get waist up Massage so it's shorter. Any tips or help? Like I said, if anyone is willing to share a copy of their notes to help me expand and be more explanatory that would be great. Thanks!


I think your SOAP note "problem" is just a symptom of an underlying and far greater series of questions.

What kind of intake do you do with your clients? Are you obtaining new information on each return visit? Are you reassessing them for pain, ROM, etc.? Are you noting changes in their posture, movements, and the way they describe their symptoms since the last session? Have they learned anything new from their other health care providers or had a change in any other forms of treatments? Have their daily activities changed recently? How is that old issue that used to bother them before the car accident? Any changes in medications?

All of that is stuff for your S and O.

If there are changes in the S and O, then you should be changing the work you do accordingly. If the S and O change but your work does not, why is that?

If your clients all have different case histories, health backgrounds, body types, dispositions, etc.... then your work should change accordingly for each person. If your work does not change for each person, why is that?

From your post, I have a strong impression that you are a relatively new graduate and have not yet obtained much (if any) continuing education. It is easy to stick to the standard techniques and strategies taught in massage school, but I feel it is a grave disservice to clients. Each person is different from every other person, and their body will be different in some way every time you see them.

Stock routines are a professional dead end... you need to go outside the box and question why you were taught to do certain things in certain ways. Don't accept the reasoning presented in school - look at the anatomy and physiology and case history to figure out whether those SCMs and scalenes really need to be stripped, or stretched, or whatever. Do you always need to use effleurage first? Do you need to work the arms at all? When do you work the hip flexors, first, last or somewhere in the middle? Will the occipital hold do this particular client any good, or should you replace it with some other method for this session? Is reflexology always the best way to work on their feet?

The body is an endless source of creative inspiration if you cultivate a genuine interest in its properties, patterns, and mysteries. When you stop regurgitating the basics of massage school, you will begin to do your best work.

NOTE: None of this is intended to imply that the things you learned were in any way incorrect. What I'm trying to say is that you have to master and make them your own by exploring further and more boldly until you achieve your own understanding of them. Then, even with "the same old techniques", you will have far greater success and satisfaction. :D
Jason Erickson, NCTMB, ACE-CPT, AIS-TA
Massage Therapist, Personal Trainer
http://www.CSTMinnesota.com

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