Subjective: This is the section where the therapist or chiropractor records the patient’s reported symptoms and feelings. It includes the patient’s description of pain, discomfort, or the reasons prompting the visit. For example, a patient may report a stiff neck with pain rating 6 out of 10 on the pain scale.
Objective: Here, the healthcare provider documents objective, measurable findings from the physical examination. For chiropractors, this may include range of motion tests, palpation, and orthopedic assessments. Massage therapists might note muscle tension, presence of knots, or swelling.
Assessment: In this critical section, the therapist or chiropractor synthesizes subjective and objective information to make a clinical judgment. This may involve diagnosing the source of pain or discomfort and determining the progress of the patient’s condition.
Plan: The final section outlines the proposed treatment plan, including the type, frequency, and duration of treatment. It also includes patient education, home care recommendations, and any referrals to other healthcare providers.
The importance of SOAP notes to massage therapists and chiropractors cannot be understated. First, they provide a structured method for recording a patient’s care and response to treatment, which is essential for continuity of care. This structure ensures that any therapist or chiropractor who sees the patient can quickly understand the patient’s history and current treatment protocol. It enhances communication among healthcare providers, leading to more coordinated and effective care.
