Intake Forms & SOAP Notes
Greetings and Welcome! I'm Kirby and I'll be your therapist, I've got this Intake form for you to get started on. Have a seat, can I get you a water? Why do massage therapists insist on intake forms and what sort of session notes do they take? Intakes & SOAPs are the documented bookends to a massage treatment.
The important thing to remember about intake forms is that they are essentially legal documents. Therapists and clients should both treat Intakes & SOAPs with the respect and gravity of such legal documents. Should any litigation require massage documentation, the intakes & SOAPs can be subpoenaed. Client's should make an effort to be truthful with their health history, but do not have to volunteer any information they are not comfortable disclosing. Be thoughtful with any information you withhold, should any adverse reaction come from massage treatment with incomplete or inaccurate health history, your therapists is not likely to be held liable.
I once had a client who had returned an intake with their occupation listed as "ass-kicker", and while it was a disrespectful, childish attempt at intimidation, it was also a permanent part of a legal document. This story illustrates how some clients don't take their intake forms seriously.
In the same turn, therapists have the same responsibility to make their documentation notes with just as much respect and professionalism. Most therapists I've known have been very thorough and thoughtful in this regard. In my initial training, an instructor shared a story of a therapist who would draw hearts and essentially doodle on their client's documents. I've also heard colloquial reports of therapists who will make rude or inappropriate notes on client's charts. Therapists should chart with the most neutral and clinical terms- not only for respect to the client, but respect to other professionals and respect for our profession as massage therapists.
The purpose of intake forms is to provide the therapist with pertinent health history information and context to the client's dysfunction. Intakes also help the client provide informed consent to treatment (which can always be further clarified by the therapist) . With health history and focus/chief complaints provided, intakes can also help therapists formulate a treatment plan and customize the massage experience. This could include recommending specific modalities, upgrades or add-on enhancements that can further benefit the client's outcomes.
Your therapist should review your completed intake form with you behind a closed door. This allows the therapist to engage in Active & Reflective Listening. Active listening is simply listening to the client and observing/picking up on body language cues without adding or changing the client's message. Reflective listening involves relaying the client's information back to them in the therapist's own words to demonstrate understanding and to cut down miscommunication. This can include asking follow up questions and clarifying perceived emotions/feelings attached to the client's message.
If Intakes are the frontend of a massage session, the SOAP notes are the backend. SOAPs are recorded to give reminders to the therapists about the client's prior condition(s) and progress through the sessions. SOAP notes also help communicate to massage colleagues and other health/wellness professionals about the client. Sometimes outside members of a client’s health team need access to the massage documentation. Other times a specific therapist isn’t available when a client really needs to follow up with their treatment. SOAP notes provide a new therapist with a crash course about the client’s health history and previous treatments they’ve received with their regular therapist.
But what really goes in a SOAP chart? SOAP is an acronym for Subjective, Objective, Assessment, & Plan. Subjective data includes anything the client tells the therapist (written or verbalized), focus or chief complaints, activities of daily living that relieve or aggravate conditions, and symptoms (location, intensity, frequency, duration) all go under the Subjective portion. Objective information includes all findings the therapist discovers during the massage visual, palpable, and even test results (such as range of motion assessments). Objective also should list modalities/techniques used and the location/body regions where bodywork was applied. The Assessment section should include long-term & short-term goals as well as the client’s response to treatment- be that functional responses or verbalized appreciation/critique. Finally, the Plan simply records any future treatment plans or self-care recommendations made by the therapist for the client’s continued wellbeing.
Through the years, I’ve seen so many different Intakes & SOAPs. Some are very thorough and fantastic. Others could have used some more work before getting to the client’s hands. I have compiled my favorite parts of many different phenomenal intakes and SOAPs into two documents that I use in my practice. And I want to share those with other therapists who are shopping around for new client documentation. So, I’m making my Intake form and SOAP note documents available for free download on my website.
And here is how I recommend using them. Both documents are double-sided(front and back). I ask clients to fill out both sides of the Intake form on their first visit with me and once a year to catch any changes to their health history (a lot can happen in a year!). I then ask every client to fill out the front page of the SOAP note every session (client needs/requirements can change from day-to-day, let alone week-to-week or month-to-month!) and I complete the back page of the SOAP myself after each appointment. So, the Intake is filled out by the client on the first visit and annually once a year- and the SOAP’s front is filled out by clients at every appointment to set their expectations each time they’re on my table. I hope these documents will serve you, your practice, and your clientele very well- I think they’re pretty fantastic forms.
Peace and Healing,
Kirby Clark, MMT, BCTMB