From ASIS Massage Education:
S. = Subjective – Information from the client
In the subjective section of the notes, it is important to identify the following:
Why the client is there.
Identify the reason for the client’s visit.
Symptoms: What symptoms are the client experiencing .
Specifically characterize the client’s experience of each symptom’s onset, location, intensity, duration, frequency, and quality.
Activities of Daily Living.
How does the symptom or condition affect the client’s daily life?
Desired Results.
O. = Objective – Information about the client which is measurable or observable
In the objective section of the notes, it is important to:
Document your findings.
What did you find that is measurable or observable before, during and after the massage?
Describe.
The results of your observation of the client before the session, the result of any tests before or during the session
Descriptions or evaluations of posture before and after the session , movement before, during and after the session
Range of motion or specific joints or areas before, during, and after the session.
Visual or palpable observations
A. = Application – Your summarization and interpretation
In the application section of the notes, it is important to:
Record the client’s response to the session.
Summarize.
Record changes in the client’s condition.
Characterize as specifically as possible any improvement or deterioration of the client’s condition as a result of your work.
Describe how the tissue, muscle, or client as a whole did change or did not change.
Interpret the subjective and objective sections.
Describe what conclusions you draw from your interactions with the client and from the massage session. If you are working with the client on an ongoing basis, compare the “subjective” and “objective” sections of this massage to those of previous sessions.
P. = Plan – Your plan for future massage sessions, and any suggestions made to the client for improving their wellness (e.g., self-massage, stretches, relaxation techniques, fitness recommendations, exercise, referrals, etc.)
In the plan section of the notes, it is important to identify the following:
Plan for future massage sessions.
Identify what you plan to do in the next massage session: (techniques, modalities, and to what body area); how many sessions you believe are indicated.
Schedule the next session.
Goals.
What goals are indicated, long term and/or short term? Try to make the goals as objective, and as based on function, as possible.
Recommendations.
Include the client’s likes and dislikes, and if any modifications need to be included in the next massage session.
What the client will do outside of the massage sessions.
Indicate self-care measures the client can employ such as exercise, stretching, ice or heat application. If a referral is appropriate, more tests are indicated, or if the client needs something outside of your scope of practice, this would be indicated here as well.
Any exercises, personal training sessions, yoga, or flexibility exercises can be added here.
