Massage Scribe
Instructions on how to write a SOAP note only get you so far. It is usually faster to read a finished one and work backwards. Below are five complete massage therapy notes covering presentations most therapists see regularly, each followed by a short breakdown of what the note does well and what a weaker version of the same note would have looked like.
These are illustrative composites written for this guide, not records of real clients. Names, numbers, and histories are invented. Use them as a model for structure and level of detail, not as clinical guidance for any particular presentation.
1. New client, desk related neck and shoulder pain
Initial session, 60 minutes, deep tissue
Client: 34, software developer, first visit
S: Client reports aching across the tops of both shoulders and into the base of the neck, present most days for roughly eight months, rated 5/10 at rest and 7/10 by the end of a work day. Worse after long stretches at a laptop, better on weekends and after hot showers. States "it feels like I am carrying something heavy on both sides." Reports two to three headaches a week starting at the back of the skull. No previous massage. Goal for today is pain relief and to find out whether this is something massage can help with.
O: Standing posture shows forward head carriage and bilateral protracted shoulders, right slightly elevated. Palpation reveals marked bilateral hypertonicity through upper trapezius and levator scapulae, denser on the right, with taut bands through both rhomboid groups. Tender point at the right levator attachment reproduces the client's familiar headache pattern. Active cervical rotation limited to approximately 60 degrees right, 70 degrees left. Treatment: 60 minutes prone and supine, myofascial release to upper back and posterior neck, sustained compression to trigger points in right upper trapezius and levator, moderate pressure throughout, cross fibre friction to rhomboid attachments. Suboccipital release in supine, light pressure. Checked in on pressure four times, client confirmed comfortable each time.
A: Bilateral cervical and upper thoracic hypertonicity consistent with the sustained desk posture the client describes, more pronounced on the dominant right side. Tissue responded well to sustained pressure, with palpable softening through upper trapezius by mid session. Post treatment cervical rotation improved to approximately 75 degrees bilaterally. Client reported pain down to 2/10 leaving the table and noted the tender point reproduced her usual headache, which she found reassuring.
P: Recommended a follow up in one week, then reassess spacing based on how long relief holds. Demonstrated doorway pec stretch, 30 seconds each side, twice daily, and a seated upper trapezius stretch to use at her desk. Suggested raising her laptop to eye level and discussed taking a short break every 45 minutes. Advised that if headaches change in character or intensity she should see her physician.
What this does well. The Subjective section carries a direct quote and a duration, so a reader knows this is chronic rather than acute. The Objective section names specific muscles and gives rotation figures before and after, which turns a claim of improvement into a measurement. The Assessment describes findings and response without naming a diagnosis. The Plan is specific enough that next week you can ask "did you do the doorway stretch" and get a meaningful answer.
The weak version. "Client has tight shoulders from computer work. Did deep tissue on neck and back. Client felt better. Rebook in a week." Everything true, nothing usable. No baseline to compare against, no record of what pressure was used, nothing that survives six weeks of forgetting.
2. Returning client, low back, fourth session
Follow up, 45 minutes, therapeutic
Client: 47, warehouse work, fourth visit in six weeks
S: Client reports the low back ache is "the best it has been since spring," currently 2/10 at rest and 4/10 after a full shift, down from 6/10 at rest at the first visit. Says the relief from the last session held about nine days before tightening returned, an improvement on the four to five days after earlier sessions. Has been doing the knee to chest stretch most mornings, skipped it on weekends. No new injury, no leg symptoms.
O: Lumbar paraspinals palpate softer and more even than at the previous visit, with residual density on the right at approximately L3 to L5. Right quadratus lumborum still noticeably tighter than left, though the guarding seen at visit one is absent. Forward flexion now within functional range with mild end range tightness, previously limited to roughly 45 degrees. Treatment: 45 minutes prone and side lying, effleurage and petrissage to lumbar and gluteal region, sustained pressure to right quadratus lumborum in side lying, moderate to firm, roughly ten minutes. Gluteus medius and piriformis addressed bilaterally. No pressure over the spine itself.
A: Continued improvement across the treatment series, with the right sided pattern resolving more slowly than the left, which is consistent with the client's description of repeatedly loading the right side at work. Tissue quality has changed measurably since the first session and the client's own reported relief window has roughly doubled. Responded well to side lying work on the quadratus lumborum, which reached the tissue better than prone did in earlier sessions.
P: Move to a three week interval and reassess. Continue the morning stretch, and specifically discussed keeping it going on weekends since the client identified those as the days he skips. Added a standing side bend stretch, both directions, held 20 seconds, once daily. Discussed alternating which side he leads with when lifting at work where that is practical.
What this does well. It reads as part of a series. Numbers are compared against earlier visits, the relief window is tracked, and the home care follow up is specific about adherence rather than assuming it. This is the kind of note that justifies a treatment plan to a referring provider, because the progression is visible on the page.
The weak version. A copy of session three with the date changed. It happens constantly, and it is the single fastest way to make a whole file look untrustworthy.
Notes at this level of detail, in about a minute
Every note above would take five to ten minutes to type. Massage Scribe writes them from a spoken description of the session, so you talk through what you did and get back a structured note to review and adjust. It handles SOAP, PIRP, and narrative formats.
Try it free Free plan available. No card needed to start.3. Runner, calf and foot pain
Single session, 60 minutes, sports
Client: 29, training for a half marathon
S: Client reports tightness through the right calf and a sharp pain under the right heel on the first few steps each morning, rated 6/10 for the first minute then easing to 2/10. Started roughly three weeks ago after increasing weekly mileage from 15 to 25 miles. Reports new shoes about a month ago. No swelling, no numbness. Goal is to keep training if that is reasonable.
O: Palpation reveals significant hypertonicity through the right gastrocnemius and soleus, with taut bands through the medial head. Marked tenderness at the medial calcaneal tubercle and along the plantar fascia on the right. Left side comparatively normal in tone. Ankle dorsiflexion visibly reduced on the right against the left. Treatment: 60 minutes, effleurage and petrissage to bilateral posterior lower leg, sustained stripping to right gastrocnemius and soleus, firm pressure, cross fibre friction along the right plantar fascia, moderate pressure, roughly eight minutes. Gentle mobilisation of the right ankle within comfortable range.
A: Right posterior lower leg hypertonicity with associated plantar fascia tenderness, appearing alongside a recent and substantial increase in training volume. Calf tissue softened noticeably with sustained work and dorsiflexion improved by end of session. Client reported the plantar work as uncomfortable but tolerable and noted immediate reduction in heel tenderness on standing.
P: Recommended a follow up in one week during continued training. Home care: calf stretch against a wall, 30 seconds each side, twice daily, and rolling the right foot over a frozen water bottle for five minutes in the evening. Suggested the client discuss the mileage increase and the new shoes with a coach or running specialist. Advised that morning heel pain persisting or worsening beyond a few weeks warrants assessment by a physician or podiatrist.
What this does well. The Subjective section captures the two details that explain the whole presentation, the mileage jump and the new shoes, because the therapist asked. The Plan refers out appropriately without overstepping. Note that the Assessment describes the pattern without ever writing the words plantar fasciitis, which would be a diagnosis.
4. Prenatal, second trimester
Single session, 60 minutes, prenatal
Client: 31, 24 weeks pregnant, second visit
S: Client reports low back ache and hip discomfort, 4/10, worse in the evenings and when standing for long periods. Sleeping poorly, waking three or four times a night. Confirms pregnancy is progressing normally, has had no complications, and has clearance from her midwife for massage. Reports the previous session helped for about five days. Goal is comfort and better sleep.
O: Positioned in left side lying throughout with pillow support under the head, between the knees, and under the abdomen. Palpation shows bilateral tightness through quadratus lumborum and gluteus medius, slightly greater on the right, and general tension through the lumbar paraspinals. Treatment: 60 minutes, effleurage and petrissage to back, hips, and legs, light to moderate pressure, sustained gentle pressure to gluteus medius bilaterally. Avoided deep pressure on the medial legs and did not work the abdomen. Repositioned to right side lying at 30 minutes. Client checked for comfort throughout and reported no dizziness at any point.
A: Musculoskeletal discomfort consistent with the postural changes of the second trimester. Tissue responded well to moderate pressure in side lying and the client reported the hip discomfort easing substantially during the session. Positioning was well tolerated with no adverse response.
P: Recommended fortnightly sessions through the third trimester, adjusting frequency to comfort. Suggested a pillow between the knees when sleeping. Advised the client to let her midwife know she is receiving massage and to contact her provider directly with any pregnancy related concerns rather than raising them at appointments here.
What this does well. Positioning, support, what was avoided, and the clearance from her midwife are all recorded. For prenatal work these are the details that matter most, and leaving them out is the most common gap in prenatal notes. The plan also draws a clean line around scope.
5. Older client, general stiffness
Single session, 45 minutes, gentle Swedish
Client: 72, retired, monthly maintenance
S: Client reports general stiffness through the shoulders, hands, and knees, worse in the mornings and in cold weather, describing it as "creaky rather than painful," 3/10. Reports a previous diagnosis of osteoarthritis in both hands, managed with over the counter pain relief. Takes a blood thinner, confirmed unchanged since last visit. Enjoys the monthly sessions and reports feeling looser for about two weeks after.
O: Skin fragile in appearance, particularly on the forearms. Palpation shows generalised tightness through both shoulder girdles and mild swelling around the finger joints bilaterally. Treatment: 45 minutes, light Swedish throughout, extended gentle work on both hands and forearms, passive range of motion at the shoulders within comfortable range. Pressure kept light throughout given anticoagulant use, no deep or sustained compression anywhere. Extra bolstering under the knees in supine for comfort.
A: Generalised stiffness consistent with the client's reported history and her description of cold weather aggravation. Responded well to light work, with visible easing of shoulder guarding and the client reporting her hands felt "much looser" by the end. No bruising or adverse response observed during the session.
P: Continue monthly. Suggested warm water soaks for the hands in the morning and gentle finger range of motion daily. Client to report any bruising following the session at the next visit. No changes to pressure or approach recommended.
What this does well. The medication is recorded along with the specific adaptation it caused. That connection, stating not just that the client takes an anticoagulant but that pressure was kept light because of it, is what shows clinical reasoning. The note also records what was watched for afterwards.
The pattern across all five
Read together, the same handful of habits show up in every strong note.
- A number attached to pain, and a comparison where one exists
- Actual muscle names rather than body regions
- Pressure and duration recorded, not just technique
- Anything avoided, and the reason for avoiding it
- Assessment that describes findings and response without diagnosing
- Home care specific enough to follow up on next time
None of that requires more writing than a vague note does. It mostly requires deciding in advance what you are going to capture, which is what a template is for. If you are still working out which format suits your practice, the comparison of SOAP, PIRP, and narrative covers the trade offs.