Clinical Massage Therapy SOAP Note Examples & Templates

A clinical SOAP note records four structured sections—Subjective client symptoms, Objective palpation and ROM findings, Assessment of tissue response, and Plan for ongoing care—which The SOAP Book generates automatically in 60 seconds.

Example 1: Cervical & Upper Trapezius Tension Headache

S: Client reports 7/10 bilateral suboccipital tension radiating to temples. O: Moderate hypertonicity and active trigger points palpated in bilateral upper trapezius, levator scapulae, and suboccipitals; cervical rotation limited 15° R. A: Decreased hypertonicity and improved tissue pliability post-myofascial release and NMT. P: Recommend weekly 60-min focused cervical/shoulder session x3 weeks + Ergonomic hydration/stretch protocol.

Example 2: Lower Back & Sciatic Piriformis Syndrome

S: Client presents with 6/10 aching low-back tightness and right gluteal referral after prolonged sitting. O: Hypertonicity noted in right quadratus lumborum, gluteus medius, and piriformis. A: Positive tissue softening and reduced referral sensitivity following deep tissue and PNF stretching. P: Return in 10 days for lower-crossed syndrome maintenance.

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