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client name
date
S (Subjective) Client symptoms and information given by
referring healthcare provider and by client.
O (Objective) Clinical observations derived from interview,
palpation, visual exam and posture assessment.
A (Assessment/Application) Treatment used and client re-
sponse to treatment.
P (Plan of Treatment) Treatment options, recommendations
and self-care plan.
additional notes
insurance ID number
date of injury
modality type (code) duration
modality type (code) duration
current medications
session type
duration
s.o.a.p. notes
symptoms:
location/intensity/duration/frequency/onset
Adhesion
Rotation
Pain
Tender Point
Hypertonicity
Spasm
Inflammation
Trigger point
Elevation
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This form was created as a resource by the american massage therapy association® for employees. AMTA is not held liable for any services provided.