Session Notes to Clean SOAP Records

Turns a therapist's quick, messy session notes into a tidy SOAP-style record (Subjective, Objective, Assessment, Plan) that can be filed in the client's chart.

Spa or massageBeauty and Personal Care✓ Checkedv1.0

Before and after

BEFORE · what the owner typed

Input from the therapist: "Ashok Singh, tues 3/12, 60 min, me (Bethany Yates) at Honeymere Massage Studio, 5149 Grovemere St, Ashgate. Ashok says low back tight since he moved boxes last wknd, 'worse when I sit at my desk more than an hour.' Rates it 6/10 at start, 3/10 after. Also says R shoulder stiff, no pain. Found tight erectors L>R lumbar, UT both sides tender R more, hip flexors tight when pressed. Swedish whole back, deep pressure on lumbar and glutes, trigger point on R UT, some stretching of hips. Medium to firm pressure, he was ok with it. Tissue loosened up a lot on the low back. Told him to do hip flexor stretch and walk around every hour at work. Wants to come back in 2 wks, focus low back and hips again. He said his left foot sometimes feels tingly, didn't ask about it more."

AFTER · what the skill produced

Client: Ashok Singh
Date: Tuesday, 3/12
Session length: 60 minutes
Therapist: Bethany Yates, Honeymere Massage Studio

Subjective

Low back tightness since moving boxes last weekend.
Client said it is "worse when I sit at my desk more than an hour."
Pain rated 6/10 at the start of the session and 3/10 after.
Right shoulder stiff, no pain.
Client mentioned his left foot sometimes feels tingly. No further details were recorded.

Objective

Tight erector muscles in the lumbar area, left more than right.
Upper trapezius tender on both sides, right more than left.
Hip flexors tight on pressure.
Treatment: Swedish massage to the whole back, deep pressure on the lumbar area and glutes, trigger point work on the right upper trapezius, and some hip stretching.
Pressure was medium to firm. Client was comfortable with it.

Assessment

Tissue in the low back loosened up a lot during the session.

Plan

Home care advised: hip flexor stretch, and walking around every hour at work.
Client wants to return in 2 weeks. Focus for next visit: low back and hips.

Questions for the owner

The client reported occasional tingling in his left foot. Do you want to note whether you suggested he mention it to a doctor or other licensed provider? Please confirm what, if anything, you told him.
Do you want to record which hip stretch you showed him, and how long to hold it?
What was the booked date for the next visit, if one was set?

What it does

Turns a therapist's quick, messy session notes into a tidy SOAP-style record (Subjective, Objective, Assessment, Plan) that can be filed in the client's chart. It only organizes what the therapist wrote. It does not add findings.

Use it when: Use when a spa or massage therapist needs to turn rough session notes into a clean, SOAP-style client record, such as: clean up my session notes, write this up as SOAP notes, or chart this massage session.